迟归病案分析  

Analysis of the Medical Records Failed to File in Time

作　　者：周诗国[1] 徐计德[1] 

机构地区：[1]首都医科大学附属北京友谊医院信息中心统计室,北京市100050

出　　处：《中国病案》2014年第12期4-6,共3页Chinese Medical Record

摘　　要：目的分析迟归病案的分布及迟归时间,为查找原因、采取措施缩短迟归时间、提高病案管理水平提供依据。方法获取2014年6月某院各科室迟归病案数据及出院患者人次,计算出院病案24小时回收率、迟归病案平均迟归天数及科室构成比,编制统计图表。结果各科室共有出院病案4323份,其中140份迟归,总的出院病案24小时回收率为96.76%;有2个科室出院病案24小时回收率低于90%。妇产科迟归病案最多(75份,占53.57%)。6月30日的出院病案,迟归例数最多(25份,占17.86%)。迟归病案中位迟归天数为2天。结论用统计图表可生动展示出院病案24小时回收率及迟归病案的迟归天数、时间-空间聚集性等特征,使病案管理人员能够抓住重点科室、重要时点查找病案迟归原因,并采取有针对性的措施来缩短病案迟归时间,这对提高医院的病案管理水平具有重要意义。Objective To analyze the distribution and the delay time of the delayed medical records, so that to present proof for finding out why the medical records delay happens and how to reduce the delay time and improve the medical records management.Methods Information on the medical records failed to file in time during June, 2014 in a hospital and the number of the patients discharged at the same time in the same area were collected, then the 24-hour file rates of the discharged medical records, the average delay time and the proportions of the medical records failed to file in time were computed, a few statistical charts were made. Results Among 4323 medical records of patients discharged during June, 2014 in a hospital, 140 medical records failed to file within 24 hours after hospital discharge, the whole 24-hour file rate of discharged medical records was 96.76%. There were 2 clinical sections whose 24-hour file rates of discharged medical records were less than 90%. Among the delayed 140 medical records, 75（accounting for the most, 53.57%） were from department of gynecology and obstetrics, 25（accounting for the most, 17.86%） were of patients discharged from hospital on June 30. The median delay time of the 140 medical records was 2 days. Conclusion The characteristics, such as 24-hour file rate of the discharged medical records, delay time, temporal and spatial clustering of the medical records failed to file in time can be presented vividly with statistical charts, then medical record administrators can easily find out where, when and why the medical records are delayed and take practical measurements to reduce the delay time, which is very significant for improvement of medical records management.

关 键 词：病案 迟归 24小时回收率 

分 类 号：R197.323[医药卫生—卫生事业管理]