分级诊疗制度的实施对三级医院病案质量管理影响与对策  

Potential influence of hierarchical medical treatment system on management of medical records in Grade Ⅲ hospital and our countermeasures

作　　者：杨柳[1] 陈国强[1] 张少明[1] 徐晓波[1] 史定伟[1] 柏金喜[1] 程纯[1] YANG Liu;CHEN Guoqiang;ZHANG Shaoming;XU Xiaobo;SHI Dingwei;BAI Jinxi;CHENG Chun(Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine,Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute,No.639,Manufacturing Bureau Road,Shanghai,200011,PRC)

机构地区：[1]上海交通大学医学院附属第九人民医院/上海交通大学中国医院发展研究院学科建设研究所,上海市200011

出　　处：《中国医院》2021年第5期46-47,共2页Chinese Hospitals

摘　　要：病案文书是患者在住院期间医疗活动的原始记录,是综合评价医院医疗质量、技术和管理水平的重要依据。随着分级诊疗制度的逐步落实,三级综合性医院定位发生转变,着重对危重、疑难及复杂病例的诊治,对病案质量及其管理提出了严峻考验。本研究以上海交通大学医学院附属第九人民医院为例,收集其分级诊疗制度推行前后疑难危重患者占比等数据,结合医院出院病历质量检查中主要问题的变化情况,分析分级诊疗制度对三级综合性医院医疗结构调整及病案质量管理带来的影响,并探讨相应对策。Medical records are the original records of medical activities during hospitalization,and also the basis for comprehensive evaluation of hospital medical quality,technology and management.With the implementation of the hierarchical medical system moving on in our country,the tertiary general hospital will gradually turn into a central institution mainly focusing on the diagnosis and treatment of critical,difficult and complicated cases,which may bring the acid test to the hospitals and also enhance the further importance of medical records management.Therefore,we preliminarily made a retrospective review of discharged case histories from Shanghai Ninth People’s hospital,compared the different proportions of patients and major problems of medical records before and after the implementation of hierarchical medical system as well.We presume the potential influence on management of medical records due to the hierarchical medical system,and also made some countermeasures probing.

关 键 词：分级诊疗 病案管理 病案质量 

分 类 号：R197.3[医药卫生—卫生事业管理]