2020年湖北省医疗机构归档病案管理质量控制指标现状调查  

Investigation on Quality Control Indicators for Archived Medical Records Management in Medical Institutions in Hubei Province in 2020

作　　者：何艺[1] 周云[1] 高红[1] 刘佩 He Yi;Zhou Yun;Gao Hong;Liu Pei(Department of Medical Records,Tongji Hospital Affliated to Tongji Medical College,Huazhong University of Science and Technology,Wuhan 430030,Hubei Province,China;不详)

机构地区：[1]华中科技大学同济医学院附属同济医院病案科,湖北省武汉市430030

出　　处：《中国病案》2023年第9期6-9,共4页Chinese Medical Record

基　　金：湖北省卫生健康委员会科研项目(WJ2021M120)。

摘　　要：目的了解2020年湖北省医疗机构归档病案质量管理质量控制现状,为提高病案质量提供依据。方法通过全国医疗质量数据抽样调查网络平台,获得2020年1月1日-2020年12月31日湖北省二级及以上医疗机构归档病案管理质量控制指标,使用Excel2010对数据进行整理和描述性分析。结果纸质病案和电子病历2个归档方式共存的医疗机构数占62.39%,纸质病案和电子病历2日归档率分别为51.82%和58.33%;出院患者病案归档完整率为97.44%,甲级病案率为96.64%,知情同意书的规范签署率为98.56%;医师填写主要诊断和主要手术正确率分别为89.42%和89.54%,编码正确率则为91.05%和92.17%。结论大部分医疗机构采用纸质和电子病历同时归档技术,病案2日归档率偏低;病案质控抽检率低;主要诊断和主要手术编码正确率略高于填写正确率。Objectives This study aims to investigate the quality management and quality control of archived medical records in medical institutions in Hubei Province in 2020,so as to provide evidence for improving the quality of medical records.Methods Through the national medical quality data sampling survey network platform,the quality control indicators for the management of archived medical records in secondary and above medical institutions in Hubei Province from January 1,2020 to December 31,2020 were obtained.Excel 2010 was used to organize and descriptively analyze the data.Results The number of medical institutions where paper medical records and electronic medical records coexist accounted for 62.39%.The 2-day filing rates of paper medical records and electronic medical records were 51.82%and 58.33%respectively.The complete filing rate of medical records of discharged patients was 97.44%.The rate of Grade A medical records was 96.64%.The standard signing rate of informed consent was 98.56%.The correct rates of physicians flling in the main diagnosis and major operations were 89.42%and 89.54%respectively,and the correct rates of coding were 91.05%and 92.17%.Conclusions Most medical institutions adopt simultaneous archiving technology of paper and electronic medical records.The 2-day filing rate of medical records was low.The sampling rate for quality control of medical records was low.The correct rate of main diagnosis and main operation coding was slightly higher than that of filling in the correct rate.

关 键 词：病案归档 内涵管理 病案质量 

分 类 号：R197.323[医药卫生—卫生事业管理]