浅谈病案管理中出现的问题

Present existing problems in the management of medical record

目的探讨病案管理中出现的问题,建立相关的监控体系,完善相关制度,进一步提高病案整体质量。方法对我院2012年全年病案管理中出现的问题进行分析总结。结果全年归档病案1 568份,病案书写质量问题32份,占比2.04%;各种检验、检查回报遗失23份,占比1.46%;病案归档问题21份,占比1.33%;病案编码问题8份,占比0.51%;病案遗失3份,占比0.19%。结论加强病案从书写到归档、登记、上架每一步的管理,可以使因为病案问题带来的医疗纠纷消失在萌芽中,对提高医院的医疗技术和科学化管理具有相当重要的作用。

Objective To investigate the present existing problems in the management of medical record to perfect of related systems and elevate the quality of medical record. Methods The existing problems in the management of medical record of our hospital in 2012 were analyzed and summed. Results Thirty-two copies,of all 1 568 archived medical records,have the writing quality problems. The incidence is 2.04%. Twenty-there copies lost the check lists and the incidence is 1.46%. Twenty-one copies have the pigeonhole problems and the incidence is 1.33%. Eight copies have the coding problems and the incidence is 0.51%. Three medical? Records are lost and the incidence is 0.19%. Conclusion To strengthen the management of medical records from writing to archiving,registrating and pigeonhole to make the medical disputes related medical record problems disappear in the bud.