山西省282所医院病案科现状调查  

Investigation on the Status Quo of Medical Record Departments in 282 Hospitals in Shanxi Province

作　　者：宋艳龙 卫蕊[1] 成晶 王玉红 Song Yanlong;Wei Rui;Cheng Jing;Wang Yuhong(Linfen People's Hospital of Shanxi Province,Linfen,Shanxi Province,041000,China;不详)

机构地区：[1]山西省临汾市人民医院,山西省临汾市041000 [2]山西省医疗服务评价中心,山西省太原市030000

出　　处：《中国病案》2023年第11期12-14,共3页Chinese Medical Record

摘　　要：目的了解山西省二、三级医院病案管理现状,为加强山西省病案科(室)建设提供科学依据。方法采用随机抽样法,于2022年1月1日-2022年3月31日对山西省282所二级及以上医院的病案室设置、业务范围、人员学历及专业构成、病案质控等情况开展问卷调查,共发放调查表282份,回收调查表282份,合格率100%,回收后的调查表统一录入Epidata3.0,数据导出后采用Excel2016软件进行整理,统计学检验采用SPSS 26.0软件,P<0.05差异有统计学意义。结果53.90%的医院独立设置病案科(室);85%的医院病案科(室)承担病历整理、病案归档、病案统计和病案复印业务,12.41%的医院病案科有患者信息采集、病案扫描、随访业务;大专及以下、本科学历、硕士及以上学历占比分别为41.47%、50.84%、7.68%;初级职称、中级职称、高级职称占比分别为50.47%、40.14%、9.39%;平均每家医院病案科专职从事编码人员数为1.90人,编码人员日均负担出院患者病历数为54.70份,开展终末病案质控、运行病历质控、病案首页质控和首页编码质控分别占49.29%、23.59%、88.77%和82.27%;人工质控占医院总数的98.23%。结论山西省各级医院病案科存在科室管理隶属关系复杂、人员专业水平参差不齐、医院管理水平差别显著等诸多问题,各医院应重视病案管理工作,提升病案管理质量水平。Objectives This study aims to understand the current situation of medical record management in the second and third-level hospitals in Shanxi Province and to provide a scientific basis for strengthening the construction of medical record departments in Shanxi Province.Methods The method of random sampling was used to select the data from 282 second-level and above hospitals in Shanxi Province,including the setting of medical record rooms,business scope,personnel education and professional composition,medical record quality control work,etc.A questionnaire survey was conducted from January 1,2022 to March 31,2022.A total of 282 questionnaires were distributed,and 282 questionnaires were recovered,with a qualified rate of 100%.The recovered questionnaires were uniformly entered into Epidata3.0.The data were exported and sorted out using Excel 2016 software.SPSS26.0 software was used for statistical tests,and P<0.05 was statistically significant.Results Only 53.90%of the 282 hospitals set up independent medical record departments(rooms).The medical record department(office)of the hospital undertook 85%of the business of medical record collation,medical record filing,medical record statistics,and medical record copying.Only 12.41%of the hospitals had the business of patient information collection,medical record scanning,and follow-up.The male-to-female ratio was 1:3.9.The proportion of college degrees and below,bachelor's degree,and master's degree and above was 41.47%,50.84%,and 7.68%respectively.The proportion of professional title structure(junior,middle,and senior)in the medical record department was 50.47%,40.14%,and 9.39%respectively.The average number of full-time coding personnel in the medical record department of each medical institution was 1.90,and the number of medical records discharged by the coding personnel per day was 54.70.The quality control of final and final medical records,operational medical records,home page of medical records,and home page of medical records accounted for 49.29%,23.59%,88.77

关 键 词：病案管理 科室设置 人员配置 现状调查 

分 类 号：R197.323[医药卫生—卫生事业管理]