内科病案延迟归档的影响因素分析  

Influencing factors of delayed filing of medical records in the internal medicine department

作　　者：谷玉婷 翁俊 彭志刚[1] Gu Yuting;Weng Jun;Peng Zhigang(The First Affiliated Hospital of Sun Yat-sen University,Guangzhou 510080,China)

机构地区：[1]中山大学附属第一医院,广东广州510080

出　　处：《中国医院统计》2021年第5期447-451,共5页Chinese Journal of Hospital Statistics

摘　　要：目的探讨病案延迟归档的影响因素,为提高病案7个工作日归档率提供对策。方法搜集某医院2019—2020年每年第4季度病案归档数据,运用logistic回归分析筛选影响因素。结果 logistic回归分析显示,病案延迟归档的保护因素为精细化病案管理政策(OR=0.341)和适中的主治医师月经管出院患者数(OR;=0.371);危险因素分别是转科(OR=1.901)、再次入院(OR=1.337)、手术(OR=1.737)、按病种分值付费医保(OR=1.542)、当月有大型节假日(OR=1.864)、较高的主治医师月经管出院患者数(OR;=1.743)、病例分型(OR;=2.669,OR;=1.809,OR;=2.487)以及较长的住院天数(OR;=1.659;OR;=2.038)。结论病案延迟归档受多种因素影响。开展精细化的病案管理政策,适当的主治医师工作量,同时重点管理具有延迟归档危险因素的病案,可有效提高病案7个工作日归档率。Objective To explore the influencing factors of delayed filing of medical records, and to provide countermeasures for improving the filing rate of medical records within 7 working days.Methods The medical record filing data in the fourth quarter of each year from 2019 to 2020 in a hospital were collected, and the influencing factors were screened by logistic regression analysis.Results Logistic regression analysis showed that the protective factors of delayed filing of medical records were refined medical record management policies(OR=0.341) and moderate number of inpatients discharged by the attending physician per month(OR;=0.371). Risk factors were transfer of departments(OR=1.901), readmission(OR=1.337), operation(OR=1.737), medical insurance of diagnosis-intervention packet(OR=1.542), month with long holidays(OR=1.864), great number of inpatients discharged by the attending physician per month(OR;=1.743), case classification(OR;=2.669, OR;=1.809, OR;=2.487) and longer length of stay(OR;=1.659;OR;=2.038).Conclusion Delayed filing of medical records is affected by many factors. Carrying out refined medical record management policies, regulating appropriate workload of attending physicians and focusing on the management of medical records with delayed filing risk factors, can effectively improve the filing rate of medical records within 7 working days.

关 键 词：病案归档 病案回收 病案管理 LOGISTIC回归 

分 类 号：R197.323.1[医药卫生—卫生事业管理]