摘要
目的调查宜宾市50家医院的病案科室管理现状,规范病案科档案工作,提高病案科管理人员的专业素养。方法2023年6月15日通过发放调查问卷的形式,对宜宾市的50家医院进行调查。将数据整理后全部输入到Epidata 3.1系统中,对数据进行描述性分析。结果在50家随机抽取被调查的医院中,有24家使用了国际疾病分类医保版编码库,20家使用了国家临床版2.0(2022汇总版)编码库。三级医院开展病案邮寄服务的有64.29%,二级医院有52.78%,三级医院全部使用了电子病历,二级医院77.78%使用了电子病历。调研医院中病案管理工作人员以大专及以下学历为主,参加进修的医院有18家。所有调研的医院都对住院病案进行管理,其中9家同时管理住院、门诊、急诊病案。结论宜宾市病案管理存在的主要问题是病案管理人才和技术人才匮乏;病案的品质管控不力,病案质检率过低。但随着对病案管理工作重视程度的不断加深,宜宾市50家医院病案科的病案管理工作正在逐步提高。
Objectives This study aims to investigate the current management status of medical record departments in 50 hospitals in Yibin City,with the aim of standardize the archive work of the medical records department and improve the professional quality of the medical records department managers.Methods On June 15,2023,a survey was conducted on various hospitals in Yibin City through the distribution of questionnaires.The data were organized and input into the Epidata3.1 system for descriptive analysis.Results Among the 50 surveyed medical institutions,24 used the International Classification of Diseases ICD-11 coding library and 20 used the national clinical version code library.64.29%of tertiary hospitals provided medical record mailing services and 52.78%of secondary hospitals provided medical record mailing services.All tertiary hospitals used electronic medical records,and 77.78%of secondary hospitals used electronic medical records.The medical record management staff in the surveyed hospitals were mainly college graduates or below,and 18 hospitals participated in further training.All hospitals surveyed managed inpatient medical records,and 9 of them managed inpatient,outpatient,and emergency medical records at the same time.Conclusions The main problems in medical record management in Yibin are the lack of medical record management personnel and technical personnel.The quality control of medical records is ineffective,and the quality inspection rate is too low.However,with the increasing emphasis on medical record management,the medical record management work of the medical record departments of 50 hospitals in Yibin City is gradually improving.
作者
朱必刚
蒲月英
Zhu Bigang;Pu Yueying(Department of Medical Records and Statistics,Yibin First People's Hospital,Yibin 644000,Sichuan Province,China;不详)
出处
《中国病案》
2024年第9期1-3,共3页
Chinese Medical Record
关键词
病案管理
情况调查
人员水平
质控管理
Case management
Situation survey
Staffing level
Quality control management
