病案归档措施实施前后效果对比  

Effect Contrast of Before and After the Implementation of Medical Records Archiving

作　　者：阮鹤瑞[1] 刘晓明[1] 傅凯丽[2] 苏晓津[3] 

机构地区：[1]新疆军区第23临床部 [2]新疆军区联勤部卫生处 [3]兰州军区乌鲁木齐总医院干部病房

出　　处：《中国病案》2015年第6期4-6,共3页Chinese Medical Record

摘　　要：目的寻找临床科室病案3日(死亡7日)归档率的对策。方法选取某医院2012年9月份与实施改进措施后的2014年3月份出院患者病案3日(死亡7日)归档情况进行统计分析。结果通过采取改进措施前后全院各临床科病案归档率进行对比,病案归档率由2012年9月份全院平均归档率52.91%,采取改进措施后的2014年3月份全院平均病案归档率提升至96.64%,前后全院平均增幅43.73%,增幅最大的软伤科达64.53%;综合内科病案归档率已达99.39%。结论医院领导重视病案管理,各级加强了病案归档流程的落实力度,强化了医务人员病案归档及时性的法律意识及奖惩机制,有效的促进了病案3日(死亡7日)归档率的提升。Objective To find countermeasures of three days （death 7 days） archiving rate of clinical department medical record. Methods Analyzing the archiving of three days （death 7 days） before （September 2012） and after （March 2014） improvement measure. Results Medical record archiving rate increased from 52.91%（September 2012） to 96.64%（March 2014）, the average growth of 43.73%. The largest increase in soft hurt department is 64.53%; General internal department has reached 99.39%. Conclusion Hospital management leadership pay attention to the medical record management, strengthen the efforts at all levels to implement the medical record archiving processes, and strengthen the timeliness of legal awareness and incentive mechanisms for medical personnel medical records archive, effectively promote the upgrading medical record three days （death on the 7th） filing rate.

关 键 词：病案归档 措施 效果对比 

分 类 号：R197.323[医药卫生—卫生事业管理]