摘要
目的了解西宁市病案管理现状,为推进病案学科建设提供可靠依据。方法2020年3月1日-2020年6月1日,对西宁市35家二级及以上医疗机构病案科(室)的设置、人员配备、病案质控等工作开展实名制电子问卷调查。结果调查35家医疗机构中,病案科为独立科室3家,占8.57%,隶属于医务科30家,占85.71%;实际开放床位数与病案人员配备比131.66:1,男女比1:4.31,护理及其他专业占60.14%,初级和无职称人员占61.59%,开展终末病案质控的医院51.43%,运行病历质控占28.57%;电子病历应用水平分级参差不齐,无纸化病案保存仅占5.71%。结论西宁市病案科人员不足,专职人员学历、专业及职称配备不合理,建议合理规划病案的学科建设,优化人力资源配置,推进精细化管理,不断满足现代管理对病案的工作要求。
Objective to understand the current status of medical record management in Xining city,and to provide a reliable basis for promoting the construction of medical record discipline.Methods From March 1 st,2020 to June 1 st,2020,a real-name electronic questionnaire survey was conducted on the establishment,staffing and quality control of medical records in 35 secondary and above medical institutions in Xining City.Results Among the 35 medical institutions investigated,3 medical record departments(8.57%)were independent departments,and 30 medical departments(85.71%)were subordinate to medical departments.The ratio of actual number of open beds to medical record staffing was 131.66:1,the ratio of male to female was 1:4.31,nursing and other professions accounted for 60.14%,junior and non-professional personnel accounted for 61.59%,hospitals carrying out quality control of terminal medical records accounted for 51.43%,and medical record quality control accounted for 28.57%;The classification of the application level of electronic medical records is uneven,and the preservation of paperless medical records only accounts for 5.71%.Conclusions The medical record department in Xining city was short of staff,and the professional education,professional title and professional title of full-time staff were not reasonable.It was suggested to rationally plan the discipline construction of medical record,optimize the allocation of human resources,promote fine management,and continuously meet the work requirements of modern management on medical record.
作者
罗秀梅
王丽梅
刘谊蓉
Luo Xiumei;Wang Limei;Liu Yirong(The Ministry of Science and education,The First People's Hospital of Xining,Xining 810000,Qinghai Province,China;不详)
出处
《中国病案》
2021年第5期8-10,90,共4页
Chinese Medical Record
基金
西宁市科技项目计划(2018-M-20)。
关键词
病案
管理
现状
分析
Medical record
Management
Current status
Analysis
