病案管理中的主动服务

Active Service in the Management of Medical Records

为了提高病案的利用率和病案科的服务质量,首先分析病案管理现状,存在的主要问题有病案资料不完整和病案管理人员不足等,直接影响了病案的利用率。从而提出病案管理人员主动服务的理念。主动与临床科室沟通,了解临床科室的需求,满足临床科研、评审等需求;了解与编码有关的医学知识,提高编码的准确性。主动了解医院管理的需求,提高准确的统计信息。主动了解患者的需求,提供良好的复印服务。同时制定相关的制度,以保证病案管理质量,确保提供信息的准确性。增强主动服务意识,可提高病案信息的利用率,促进病案管理水平的提升。

To improve the utilization rate of medical records and the service quality of medical record department, we found many major problems that directly affecting the utilization rate of medical records such as incomplete medical record materials, insuffi- cient of management staffs and so on through analyzing the current status of the management of medical records. Then we put for- ward the conception of active service, examples such as through initiatively communicating with clinical departments, we can acquire and satisfy their needs of clinical research or review of them, to study relevant medical knowledge about coding and increase its accura- cy, to initiatively understand the requirements of hospital management and provide accurate statistical information, to acquire the needs of patients and provide well copying service. And also, we should revise relevant regime to ensure the quality of medical records and the accuracy of the information provided. To strengthen the awareness of initiative service, we can expect to improve the utiliza- tion rate of medical records information and promote the progress of the level of medical records management.