某医院2011年-2012年病历档案复印情况分析

Analysis on the Duplication Status of Medical Records in a Hospital from 2011 to 2012

目的随着国家社会医疗保险的普及,人民的保险意识逐渐加强,使得病案的利用率不断增加。通过总结,为我们今后从提高病案管理质量和复印病历工作服务方向上进一步科学化提供依据。方法本文通过对某三甲医院2011年-2012年出院患者病历档案复印情况进行分类统计分析。结果 2011年病历复印总数为12793人,2012年病历复印总数为15220人,2012年较2011年增长了19%。医疗保险报销复印病历数居首位;办理大病医保、重症慢性病鉴定位居第二。结论病案的复印需求逐年增加,要求临床医师在保证病历质量的同时及时完成病历。要求病案管理人员在提供病历复印时,严格按照相关制度办理复印。在保证病历安全的情况下,为复印病历者提供优质服务。科学、完善病历档案复印服务流程,是提高我们病案管理质量的一个重要组成部分,我们通过病案复印窗口的优质服务,来提升病案服务的满意度,从而增加患者对医院的满意度。

Objective With the popularity of national social medical insurance, the insurance consciousness of the people was reinforced gradually, which led the utilization of the medical records increased continuously. We summarized and provided evidence for the further scientization in the future in two aspects, improving the quality of medical record management and the service of medical records duplication. Method To conduct a classification statistical analysis on the medical records duplication status of discharged patients from 2011 to 2012 in a grade three and first-class hospital. Result The total duplication number of medical records was 12793 in 2011, while the number was 15220 in 2012 and increased 19% compared with 2011. The number of duplication for medical insurance reimbursement was in the first place, and for the identification of serious illness insurance, severe chronic disease was in the second place. Conclusion The demand of medical records duplication is increasing year by year, which requires the clinicians to finish the medical records timely with quality guaranteed. The medical records staff should conduct duplication work in strict accordance with the relevant system when provide medical records duplication, and offer high quality service for patients with the assurance of the safety of medical records. A scientific and perfect medical records duplication service process was an important component in the improvement of the quality of medical records management. We promote the degree of satisfaction of medical records service through the high service of duplication window, so as to increase the satisfication of the patients to the hospital.