病案管理考核评分标准与实践

Assessment Standards of Health Records Management and Practice

目的 探讨提高无锡市病案管理专业整体水平的方法。方法 由学科带头人起草内容全面、可操作性强的“病案管理考核评分标准”。再经市卫生局审定 ,以“医政文件”下发各医院执行。市卫生局组织定期的“规范化病案室”评审。结果 通过调查表明 ,无锡市各医院病案管理专业的“软件”和“硬件”建设都有明显发展 ,专业整体水平有较大提高。结论 制定“病案管理考核评分标准”和评审“规范化病案室”是提高病案管理整体水平的有效方法。

Objective To explore the means to improve the entire specialized level of Hospital Health Records Management in Wuxi. Methods To draft a full and operative “Assessment Standards of Health Records Management” by the subject leader and then issue to every hospital in Wuxi as official “Medical Document” after being examined by the Municipal Health Bureau. The Municipal Health Bureau will have regular assessment for “Standardized Health Records office.” Results Investigations show that distinct improvements have been made in both “software and hardware buildup” for Health Record Management in all hospitals while the entire specialized level has been greatly upgraded. Conclusion The formulation of “Assessment Standards of Health Records Management” and the assessment of “Standardized Health Record office” are quite effective measures to upgrade the entire specialized level of Health Records Management.