湖北省二级医院病案科(室)建设现状调查

Status Investigation of Departments(Offices) of Medical Records in the Second Level Hospitals of Hubei Province

目的了解湖北省二级医院病案科(室)建设现状,为加强病案科(室)建设提供依据。方法通过问卷法调查湖北省二级医院病案科(室)的组织管理、人员配置、科研培训、信息化管理及科室制度建设现状。结果 54.44%的病案科(室)归医务处管理,病案工作人员业务用房面积大于50m2病案科室仅占20.11%,病案管理者专业背景以护理(28.36%)和临床医学(16.36%)专业居多,10项病案科室制度的覆盖率均在70%以上。结论病案室制度建设较完善,但科室隶属关系不合理,基础设施严重不足,从业人员结构不合理,信息化管理水平参差不齐等。

Objective To find out the current situation of Departments （offices） of Medical Records in the second level hospitals of Hubei Province. Method Questionnaires were used to survey the management, employment structure, scientific research, computer- ized management and institutional improvement of Departments （offices） of Medical Records. Result Firstly, 54.44% of the total De- partments { offices） of Medical Records were administratively subject to the department of medical affaires. Secondly, the area of busi- ness room for medical record managers was mostly less than 25m2. Thirdly, the major of the managers are mainly Nursing and Clinical medical. Finally, the 11 medical records rules were used in more than 70% of departments （ offices }. Conclusion The construction of medical record system is fairly perfect. However, the relationship of department subordinate is not reasonable. Meanwhile, the infrastructure severity shortage and employment structure is unreasonable and information management level is uneven.