病历归档及时性管理心得体会

Timeliness Management Feelings and Experiences of Medical Records Archiving

目的探讨出院病历及时归档的管理方法。方法通过对病案及时归档重要性的分析,发现病历迟归的原因。在实际工作中,建章立制,设计一套科学的病历归档管理软件,公平、透明的产出"病历归档及时率月报表"对临床科室进行公平的归档质量评价,将"病历七日归档率"指标纳入医院"医疗质量与安全考核指标"系统中进行常态化监督管理。结果通过两年的实践管理和不断改进,出院病历的归档及时率大大提高,并能最终保持在目标范围内。结论病案管理人员要加强认识,勇于担当,要有管理意识。病历归档及时性管理要有完整的、可实际操作执行的制度、措施和评价分析系统。在工作中要注重和临床医师及相关部门的沟通,做到公正公平,持续改进,在保证病历质量的前提下,努力提高病案归档及时率。

Objective To investigate the management methods of timely hospital medical records archiving. Method To find the reason for late return of medical records through analyzing the importance of medical records archiving in time. Building rules and reg- ulations in the actual work, and designing a set of scientific medical record archiving management software, fair and transparent out- put ＂monthly medical records archiving rate report＂ was carried out for all clinical departments, the ＂7 days archive rate of medical records ＂ was included in the hospital medical quality and safety performance targets ＂ for conducting routine system supervision and administration. Result Through two years of practice management and continuous improvement, the hospital medical records archive rate had greatly increased, and could eventually keep within the target range. Conclusion Our medical record management staff need to strengthen the understanding, take on the courage to undertake, and have management consciousness. The medical record archive management should have complete actual operation system to be carrying out, as well as relevant measures and evaluation system. It should be paid attention and timely communication with clinicians and relative departments in daily works, and get even-handed jus- tice and continuous improvement. To improve medical record archiving rate on the premise of guarantee the quality of medical records.