新医改背景下病案信息的利用与管理  

The Utilization and Management of Medical Record Information Under the Background of the New Medical Reform

作　　者：孙丽[1] 陈丽娟[1] 梁力中[1] 梁翠翠[1] 

机构地区：[1]广东医学院附属医院,湛江市524001

出　　处：《中国病案》2016年第3期4-6,共3页Chinese Medical Record

基　　金：广东省湛江市科技攻关计划项目课题(2015B01116)

摘　　要：目的通过对医院病案信息利用和管理情况的分析,探讨在新医改背景下如何开发和利用病案信息资源。方法收集医院2010年-2014年住院工作统计报表及病案室病案借阅登记和复印登记簿中病案利用的相关数据,应用SAS 9.2统计软件对病案利用情况进行对比及卡方趋势分析。结果随着出院患者的逐年增加,病案利用率也呈现逐年增长,由2010年的28.9%增长至2014年的32.82%,经卡方趋势检验P<0.0001,具有显著统计学差异;院内临床科研人员对病案的调阅利用情况也呈现逐年上升的趋势,从2010年的7205份增加至2014年11 200份,增长率为55.45%;院外医疗保险的病案利用从2010年的5715份增长至2014年的9534份,增长率为63.67%。结论病案在临床科研、医院管理以及医疗保险赔付等方面的利用率逐年增加,医院在病案管理方面应顺势而变,打破病案管理重保管轻利用的现状,提高病案管理的硬件配置,强化信息意识,提高服务效能,加强病案的信息化管理,促进病案信息的开发和利用。Objectives To analyze the utilization and management situation of medical record information, in order to explore a better way to develop and utilize the information resources of medical record under the background of the new medical reform. Methods To collect statistic data which about the utilization of medical record from 2010 to 2014, apply trend test to make comparison on the data of medical records utilization situation by SAS 9.2 statistic software and Chi-square tendency. Results With the increasing of discharged patients, the utilization rate of medical record rose from 28.9% in 2010 to 32. 82% in 2014 （P〈0. 0001）. The review of medical record by scientific researchers showed a rising trend, increased from 7205 in 2010 to 11200 in 2014, the growth rate was 55.45%; The copy amounts of medical record increased from 5715 in 2010 to 9534 in 2014 for medical insurance payment, increased 63.67%. Conclusions The utilization rate of medical records was continuously increasing in aspects such as clinical research, hospital management and medical insurance compensation. The hospital should change the current situation of rare utilization and emphasized storage in the management of medical records, improve the hardware configuration of medical records management, intensify information awareness, improve service efficiency, strengthen the information management and promote the development and utilization of medical record information.

关 键 词：病案信息 利用 分析 

分 类 号：R197.323[医药卫生—卫生事业管理]