摘要
目的以等级医院评审工作为契机,不断推动病案室规范化建设,提高病案归档率。方法利用医院病案管理系统调取2017年1月至2017年12月全院各临床科室出院病历进行统计分析,并通过完善病案管理制度,规范病案回收流程,加强病案多环节综合控制等方法不断提高病案归档率。结果我院2、3、7日的病案归档率由2017年1月份的43.70%、52.10%、61.54%,分别提高到2017年12月的90.89%、95.71%、97.98%,达到等级医院评审标准中的病案归档的B级要求。结论医院应重视和加强病案归档工作,建立有效的病案归档管理制度和奖惩制度,实现病案归档规范化管理。
Objective To promote the standardization of medical records room construction and improve medicalrecords filing rate by the grade hospital evaluation. Methods The discharged medical records of all clinical departmentsof the hospital from January 2017 to December 2017 were collected and analyzed, and the rate of medical records filingwas continuously improved by improving the management system of medical records, standardizing the recovery processof medical records and strengthening the comprehensive control of multiple links of medical records. Results The filingrate of medical records at the 2nd, 3rd and 7th in our hospital increased from 43.70%, 52.10% and 61.54% in January2017 to 90.89%, 95.71% and 97.98% in December 2017 respectively, achieved grade hospital evaluation standard ofthe class B requirements of medical records filing. Conclusion The hospital should pay attention to and strengthen thefiling of medical records and establish effective medical records filing management system and reward and punishmentsystem, to achieve standardized management of medical records.
作者
杨帅
孙栋
罗秀梅
施大为
陈轲
记甜莉
赵丽
常钰
YANG Shuai;SUN Dong;LUO Xiu-mei;SHI Da-wei;CHEN Ke;JI Tian-li;ZHAO Li;CHANG Yu(Medical Department,the First People＇s Hospital of Xianyang City,Xianyang 712000,China)
出处
《临床医学研究与实践》
2018年第29期197-198,共2页
Clinical Research and Practice
关键词
三甲医院
病案归档
病案管理制度
third-level first-class hospital
medical records filing
management system of medical records
