住院病案查询与复印现况分析  

Exploring the Current Situation of Hospitalized Medical Records Inquiry and Copying

作　　者：李凌[1] 杜惠芳[1] 

机构地区：[1]广州医学院附属广州市第一人民医院,广州市510180

出　　处：《中国病案》2010年第3期11-12,共2页Chinese Medical Record

摘　　要：目的分析2007年-2008年病案的查询服务和复印利用情况。方法采用随机原则,抽取2007年和2008年各10%的复印病历申请单和相关病案首页资料为研究对象。使用自行编制的调查表;SPSS10.0统计软件,采用χ2卡方检验进行统计分析。结果2007年院内外共查阅病案5000份,2008年查阅病案约8500份。因公查询复印主要为保险公司医药费理赔,复印内容最多的前三项为影像报告、出院记录、入院记录。结论病案查询、复印服务需求不断增加,服务对象来源广泛,需不断提高病案质量,培养高水平、知识全面的病案管理人员,方能满足医疗改革的需求。Objective To analyze the inquiry and copying service of medical records.Methods With the principle of completely random sampling,10% of the applications of copying the medical records in 2007 and 2008 each and related first page were extracted and investigated by self-designed questionnaires.Chi-square test was conducted by the SPSS10.0 software.Results In 2008,8500 copies of medical records have been inquired,more than 5000 copies in 2007,with an increase of 154%.Most private inquiries for copies were of patients and their families＇ source,and most public inquiries were claimed up by insurance companies,with the main purpose of insurance claims.And main contents for copying were imaging reports,discharge records and admission records.Conclusion The inquiries of medical records was increasing by and by,which need to constantly improve the quality of medical records and train high-level case management staff with comprehensive knowledge,in order to meet the demand of health care reform.

关 键 词：住院病案 复印 

分 类 号：R197.3[医药卫生—卫生事业管理]