浅谈保障病案科服务的措施  

Measures of Guarantee Service for the Medical Records Department

作　　者：欧江福[1] 刘世全[1] 周祖宏[1] 袁玉刚[1] 周孟君[1] 

机构地区：[1]四川省绵阳市中心医院信息中心,绵阳市621000

出　　处：《中国病案》2017年第6期10-13,共4页Chinese Medical Record

摘　　要：目的探讨病案科服务的保障措施,以便及时准确地将病案资料转化成可用信息,提高病案科服务能力。方法根据《三级综合医院评审标准实施细则(2011版)》要求,运用SWOT分析法分析某院病案科服务的优势与劣势、外部机遇与威胁,运用计算机技术实现信息化管理。调取某三级甲等综合医院信息系统中2014年、2015年、2016年的出院病案数据及查询同期病案服务登记簿。用SPSS 22.0对优化前后的服务指标进行t检验。结果出院病案3日内回收率提高到98.0%,7日内回收率提高到99.0%以上,2016年病案服务次数不低于同期出院病案数,人均每月服务量也从275.2次提升到422.6次。病案月均服务次数改进前4653.500?111.878次,改进后6762.170?399.336次,P<0.05,对比组之间的差异具有统计学意义(t=-17.614,P=0.000);人均月服务量改进前275.170?5.523次,改进后422.630?24.967次,P<0.05,对比组之间的差异具有统计学意义(t=-19.977,P=0.000)。结论加强病案科人文建设、加大投入、优化病案科工作流程及实现病案管理信息化是保障病案科服务的有效措施。Objective To discuss the guarantee accurate transform medical record data into usable measures of medical record service, in order to timely and information, improve the medical record department service ability. Methods According to the level 3 general hospital accreditation standards implementation details （2011 edition） requirements, using the SWOT to analyze service strengths, weaknesses, external opportunities and threats of the medical record department, and using computer technology to realize the informationization management. To retrieve the data of discharged medical records in 2014, 2015 and 2016 of a three grade a general hospital information system and inquire about the register of medical records of the same period. SPSS 22 was used to examine the service indicators before and after optimization. Results Medical records 3 days recovery rate increased to 98.0%, 7 days recovery rate increased to more than 99.0%, medical record number of service no less than the same period in 2016, per capita monthly services from 275.2 times to 422. 6 times. Medical record monthly average service times before improvement 4653. 500 ±111. 878 times, 6762. 170±399. 336 times after improvement, P〈 O. 05, the difference between the control group with significant （t=--17. 614, P=-0. 000）. Per capita monthly service before improvement 275. 170±_5.523 times per month, after improvement 422. 630±24. 967 times, P〈0. 05, the difference between the control group with significant （t=-19. 977, P=-0. 000）. Conclusion It is an effective measure to protect the service of medical record department by department, increasing investment, optimizing the informatization of medical record management. strengthening the Humanistic Construction of medical record workflow of medical record department and realizing the

关 键 词：病案科 服务 保障 措施 SWOT分析法 

分 类 号：R197.323[医药卫生—卫生事业管理]