重庆某三甲医院病案示踪管理系统的应用及改进建议  

Application and Improvement Suggestions of Medical Record Tracer Management System in A Third-Class A Hospital in Chongqing

作　　者：何银平 HE Yinping(Medical Records Room, Chinese People’s Liberation Army Special Medical Center, Chongqing 400042, China)

机构地区：[1]中国人民解放军陆军特色医学中心信息科病案室

出　　处：《中国医疗设备》2019年第6期106-109,共4页China Medical Devices

摘　　要：目的研究我院应用病案示踪管理系统对病案回收质量、病案借阅及病案流通的影响,为进一步优化该系统提供参考意见。方法自2016年8月起我院开始使用病案示踪管理系统,对比使用前后出院病案7个工作日回收率、病案借阅回归率、病案服务满意度,总结病案流通过程中出现的问题,以及系统使用过程中的不足和弊端,为开发和完善新的模块功能提供依据。结果使用病案示踪管理系统后,临床医务人员及患者对于病案各项服务满意度明显提高,与使用前比较差异均有显著意义(P<0.01);使用系统后6个月平均出院病案7个工作日回收率明显高于使用系统前,差异有显著意义(P<0.01);使用系统前后借阅病案3日回归率、1周回归率和2周回归率组间比较差异均有显著意义(P<0.01)。结论病案示踪管理系统可明显提高出院病案的回收质量、病案借阅回归率以及临床医务人员和患者对病案服务满意度,有望成为各医院的基本配置,但是在使用过程中根据使用体会不断开发和完善模块功能,保证系统的可操作性,最大限度地适应工作需要十分必要。Objective To provide suggestions for further optimization of the tracer management system by studying the influence of system applied in our hospital on the quality of medical record recovery, the borrowing of medical record and the circulation of medical record. Methods Since August 2016, the tracer management system had been used in our hospital. By comparing the recovery rate of discharged medical records in 7 working days, the regression rate of borrowing medical records and the satisfaction degree of medical records service before and after the use, the problems in the circulation of medical record as well as the inadequacies and disadvantages in the use of the system were summarized, so as to provide a basis for the development and improvement of new module functions. Results After using the tracer management system of medical record,the satisfaction of clinical medical staff and patients on various services of medical record was significantly improved, which was significantly different from that before the use(P<0.01). The average recovery rate of discharge medical records in 6 months after using the system and 7 working days after using the system was significantly higher than that before using the system, and the difference was significant(P<0.01). The 3-day rate, 1-week rate and 2-week rate of recovery of the borrowed medical records before and after the use of the system were significantly different between the two groups(P<0.01). Conclusion The tracer management system of medical records can significantly improve the recovery quality of discharged medical records, the rate of return of borrowing medical records and the satisfaction of clinical medical staff and patients with medical records service,which is expected to be the basic configuration of hospitals. However, it is necessary to develop and improve the module functions according to the user experience in the use process to ensure the operability of the system and to adapt to the work requirements to the maximum extent.

关 键 词：病案示踪 管理系统 病案回收率 病案借阅 病案流通 病案复印 功能改进 

分 类 号：R197.323[医药卫生—卫生事业管理]