摘要
目的为全面了解某市医院病案管理水平,促进病案管理专业进一步发展和重视,为建设更专业化的病案管理队伍提供客观依据。方法2019年年初采用问卷调查法,以扫描二维码收集调查119家医疗机构2018年的数据,应用Excel 2010和SPSS20.0进行整理和分析。结果某市病案科(室)大部分隶属于医务科,占比47.06%,不同等级医院病案编码人员工作负荷不一致,病案管理人员的办公面积大部分在50平方米及以下,占比68.91%,61.34%的医院病案管理硬件设备勉强满足病案管理的日常运营,病案管理队伍中病案编码人员占比47.88%,其中75.66%的编码员持有编码证,39.32%的医院病案管理流程不完整,30.77%的医院病案归档不规范,66.67%的医院病案无法示踪,超过50.00%的医院历史病案还没有进行电子存档,出院病案3个工作日回收比例只有45.3%。结论某市医院病案管理专业重视程度有待进一步提高,病案管理人员专业水平参差不齐,不同级别医院管理水平差别显著,部分医院工作流程和方式还不规范,影响数据的准确性和可靠性。
Objective To comprehensively understand the level of medical record management in a hospital,promote the further development and emphasis of medical record management,and provide objective basis for the construction of a more professional medical record management team.Methods At the beginning of 2019,the questionnaire survey method was adopted to scan the Two-Dimensional code to collect the 2018 data of 119 medical institutions.Excel 2010 and SPSS20.0 were used for sorting and analysis.Results The medical record management department of a city is mostly subordinate to the medical department,accounting for 47.06%.The workload of medical record coders in different levels of hospitals is inconsistent.Most of the office space of medical record managers is 50 square meters or less,accounting for 68.91%.38.66%of hospital medical record management hardware and equipment barely meet the daily operation of medical record management.In the medical record management team,medical record coders account for 47.88%,among which 75.66%coders hold coding certificates.39.32%of hospital medical record management process is incomplete;30.77%of hospital medical records archiving is not standard;66.67%of hospital medical records could not be tracked;More than 50.00%of hospital historical medical records have not been electronically archived;Only 45.3%of discharged medical records were recovered within 3 working days.Conclusion The professional attention of medical record management in a city hospital needs to be further improved,and the professional level and management level of medical record management personnel are different,which will affect the accuracy and reliability of medical data.
作者
唐彩云
陈彩霞
林佩珊
刘德凯
赖伏虎
Tang Caiyun;Chen Caixia;Lin Peishan;Liu Dekai;Lai Fuhu(Department of Medical record Management,Shenzhen People’s Hospital(The Second Clinical Medical College,Jinan University/The First Affiliated Hospital,Southern University of Science and Technology),Shenzhen 518020,Guangdong,China;不详)
出处
《中国病案》
2021年第2期1-4,共4页
Chinese Medical Record
关键词
病案管理
现状
调查分析
Management of medical record
Current status
Investigation and analysis
