河北省45家三级医院病案室现状调查研究  

Investigation on status quo of medical record management department in 45 tertiary hospitals in Hebei province

作　　者：吕建波 吕璐[2] 

机构地区：[1]河北省疾病预防与控制中心,石家庄市合作路42号050021 [2]中山大学中山医学院

出　　处：《中国医院》2014年第12期14-16,共3页Chinese Hospitals

摘　　要：目的:通过对河北省45家三级医院病案室进行调查,了解病案室的基本情况,为制定有关政策提供依据。方法:制定统一调查表并进行相关培训,派专门人员深入医院进行调查。结果:有71.11%的医院独立设置了病案室,有阅览室的占71.11%,电子阅览室的占62.22%;93.33%的医院拥有内网、53.33%的使用外网;有15.66%的医院无病案管理软件,11.11%的医院不能使用计算机进行医疗质量统计指标统计;22.22%的医院手工进行病案示踪;病案室工作人员平均11.5人,平均每50张开放床位拥有病案室人员0.58人,平均每家医院有编码资质人员1.7人,专兼职编码人员平均2.7人。平均病案归档率7日、3日、2日分别为97.30%、78.66%、52.20%。结论:病案管理人员普遍缺乏,专业水平和知识层次较低,职称结构和专业构成不合理,有资质的疾病分类编码人员不足,信息化建设水平滞后,病案归档率较低,严重制约当地医院病案管理信息准确、高效利用,也制约着临床路径管理、DRGs的推进和实施。Objectives：To learn the status quo of medical record management department and give evidence of policy making by investigating 45 tertiary hospitals in Hebei Province. Methods：Unified questionnaires were used by well training investigators to carry out the survey in the selected hospitals. Results：71.11% of hospitals has set up individual medical record management department and also 71.11%of hospitals have reading room. Furthermore, 62.22%of hospitals have electronic reading room. 93.33%of hospitals use specialized network and 53.33%of which use internet. There are 15.66%of hospitals has no medical record management software and 11.11% of hospitals analyze medical quality index by hand. There are also 22.22%of hospitals tracking medical record by hand. On average, there are 11.5 staffs in medical record management department per hospital and 0.58 medical record management staff per 50 beds. There are 1.7 qualified coding staff and 2.7 coding staff in practice per hospital. The average 7 days, 3 days and 2 days of medical record archive rate are 97.30%、78.66%and 52.20%respectively. Conclusions：The common problems of medical record management can be summarized as lack of staff and low quality of staff, irrational title and major structure and low degree of informatization and archive rate, which has seriously constraint hospital medical record information accuracy and efficient utilization and also constraint clinical pathway management and DRGs promotion as well.

关 键 词：三级医院 病案室 现状调查 

分 类 号：R197.323[医药卫生—卫生事业管理]