某省三级医院病案管理现状调查和分析  

Present Situation Investigation and Analysis on the Medical Records Management of a Provincial Tertiary Hospital

作　　者：马丽娟[1] 陈珍初[1] 黄后宝 

机构地区：[1]皖南医学院弋矶山医院,安徽芜湖241000 [2]安徽省病案质量控制中心,安徽芜湖241000

出　　处：《中国病案》2017年第9期1-4,共4页Chinese Medical Record

摘　　要：目的了解某省三级医院病案管理和病案质量控制工作现状,进一步规范病案管理工作,有针对性地开展全省病案管理、病案知识培训及病案质量控制工作。方法采用问卷调查法,利用Epidata3.02软件进行数据的录入,Microsoft Office Excel 2007进行描述性数据分析。结果共收到51家三级医院的调查问卷。62.75%的三级医院病案科室隶属医院医务处,纸质方式仍是最主要的病案保存方式,病案工作人员的平均配比为162.5:1,28.92%的病案工作人员为护理专业,51家三级医院只有97名病案质控专职人员,只有10家医院的病案质检率为100%,疾病分类和手术操作分类编码库的使用不统一,疾病编码人员缺乏相关知识培训。结论加强病案管理,需配备相应的病案工作人员,同时病案工作人员应从多途径提高自身素质和业务水平。疾病编码库使用版本不统一的问题需要卫生行政管理部门结合本省实际情况,借助行政手段,规范全省疾病编码库的使用。Objectives To make fully understand of the situation of Anhui tertiary hospital medical record management and medical record quality control, further standardize medical record management work, carry out targeted medical record management, medical records knowledge training and quality control in the province. Methods Using the questionnaire survey method, the data entry was carried out by Epidata3.02 software, and descriptive data analysis was carried out in Microsoft Office excel 2007. Results 51 questionnaires were received 62.75% of the tertiary hospital medical records attached to the hospital medical office; Paper mode was still the most important way to save the medical records, the average ratio of medical staff was 162.5： 1; 28.92% of medical record management staff＇ s profession was nursing; 51 tertiary, hospitals had only 97 full-time medical records quality control staffs. There were only 10 tertiary hospitals had 100%medical records quality control rate. The version of classification of diseases and operative classification code library was not the same. disease coding staff was lack of relevantknowledge training. Conclusions To strengthen medical record management, should be equipped with corresponding medical staff, medical staff at the same time should be more ways to improve their own quality and business level, increase the value of ＂used＂, improve the leadership, to the attention of the medical record management, in turn, increase the investment in medical record management, make the medical record management to a benign development stage. The problem of the use of a version of the disease coding library is that the administrative department of health should combine the actual situation in this province with the use of administrative means to regulate the use of the disease coding library in the province.

关 键 词：病案信息管理 病栗质控 疾病编码 

分 类 号：R197.323[医药卫生—卫生事业管理]