张掖市118家医院病案管理现状调查分析  

Investigation and Analysis of the Current Situation of Medical Record Management in 118 Hospitals in Zhangye City

作　　者：李海燕 代天坤 冯玉婷 Li Haiyan;Dai Tiankun;Feng Yuting(The Second People’s Hospital of Zhangye City,Gansu Province,Zhangye 734000,Gansu Province,China;不详)

机构地区：[1]甘肃省张掖市第二人民医院,甘肃省张掖市734000

出　　处：《中国病案》2023年第9期9-11,112,共4页Chinese Medical Record

摘　　要：目的了解张掖市118家医院病案管理现状,以促进当地病案管理专业进一步发展,提高病案管理水平。方法通过问卷星对118家医院2017年1月1日-2021年12月31日的病案管理现状进行问卷调查。结果118家医院共有专职病案管理人员107人,平均每家医院配备病案管理人员0.9人,其中持有编码培训合格证8人,平均每家医院配备编码员0.07人;118家医院病案科(室)均未独立设科,分别隶属于医务科、办公室、信息科、医保科等部门,96.6%病案科负责人为兼职,97.5%的医院未开展住院病案首页质控、编码及统计工作;40.6%的医院没有病案管理软件系统,97.4%的医院病案没有进行电子存档。结论张掖市医疗机构病案科隶属关系不合理,病案管理专业人员匮乏,病案管理信息建设投入不足,病案管理业务开展滞后;改变张掖市病案管理现状势在必行。Objective This study aims to understand the current state of medical record management in 118 hospitals in Zhangye City,in order to promote further development of the local medical record management specialty and further improve the level of medical record management.Methods A questionnaire survey was conducted on the current status of medical record management in 118 hospitals from January 1,2017 to December 31,2021.Results 118 hospitals had a total of 107 full-time medical record management personnel,with an average of 0.9 medical record management personnel per hospital,of which 8 had coding training certificates and an average of 0.07 coders per hospital.None of the medical record departments(rooms)of the 118 hospitals had an independent department,and they were respectively affiliated with the medical department,office,information department,medical insurance department,and other departments.96.6%of the medical record department heads were part-time and 97.5%of the hospitals did not carry out quality control,coding,and statistical work on the front page of inpatient medical records.40.6%of hospitals did not have medical record management software systems,and 97.4%of hospital medical records were not electronically archived.Conclusions The affiliation of the medical record department of the medical institution in Zhangye City is not reasonable.There is a paucity of medical record management professionals.The investment in the construction of information for medical record management is insufficient.The development of medical record management operations has lagged.It is imperative to change the situation of medical record management in Zhangye City.

关 键 词：病案管理 现状 调查 

分 类 号：R197.323[医药卫生—卫生事业管理]