重庆市乡镇(中心)卫生院病案管理现状与对策

Current Situation and Relevant Countermeasures of Medical Records Management in Public Health Centers of Chongqing

目的加强和规范乡镇(中心)卫生院病案管理工作,探讨乡镇(中心)卫生院建立病案统计管理组织架构的必要性。方法用随机抽样法和现场问卷、察看方式,对34个乡镇(中心)卫生院进行实地调查。结果 34个乡镇(中心)卫生院均没有设病案科室,没有建立病案管理制度;病案统计人员100%为兼职人员;76%的医院设有专用病案库房和病案存放架,62%的医院对出院病案进行了归档。结论随着医改深入开展,乡镇卫生院规模不断扩大,有40%以上的乡镇(中心)卫生院有建立病案统计管理组织架构的必要。

Objective To strengthen and standardize the medical records management of public health center in Chongqing, and discuss the necessi- ty of the establishment of medical records management organization chart. Methods To investigate the health center of 34 villages and towns by ques- tionaires, random sampling and observation. Results None of these 34 hospitals had a medical records office as well as medical records management sys- tem. All the personnel were part-timers, there were no store rooms and storage racks for medical records in 76% hospitals and 62% made place for files for leave hospital patients. Conduslem As the earring out of medical reform deeply and the enlarging scale of health center continuous, 40% of these health centers have the necesity to establish a medical records management organization chart.