多措并举提高出院病案24小时回收率

To Improve the 24-hour File Rate of Discharged Medical Records by Multiple Measures

目的分析某院出院病案24小时回收率,为进一步提高病案管理水平提供决策依据。方法基于某院办公信息系统公布的2014年6月、10月、11月、12月迟归病案信息和病案数字化综合管理系统提供的相应时段出院患者人次,按月计算出院病案24小时回收率。借助SAS 9.2软件,采用双向无序R×2表资料的χ2检验,并作两两比较(Bonferroni法),评价所采取措施的效果。结果 2014年6月、10月、11月、12月,出院病案24小时回收率依次为96.76%、99.49%、99.39%、99.47%。前后4个月的出院病案24小时回收率差异有统计学意义(χ2=198.2151,P<0.0001),且10月、11月、12月的出院病案24小时回收率都比6月份的高(χ2值依次为83.0866、78.9673、96.3323,P值均小于0.0001)。结论对出院病案迟归的临床科室、医护人员进行通报批评、扣发奖金、定期提醒,有效提高了出院病案24小时回收率,向杜绝病案迟归的目标迈近了一大步。

Objectives To analyze the 24-hour file rate of discharged medical records in a hospital, and provide evidence for the decision-making of improving medical records management measures and management level further Methods To calculate the monthly 24-hour file rate of discharged medical records according to the delayed archiving information of medical records in time during June, October, November and December, 2014 announced by the office information system of the hospital and the numbers of patients discharged during each of the above months provided by the medical records digitalization＇comprehensive management system. With the application of SAS 9.2, Chi-square test for R × 2 contingency tables as well as multiple comparison （Bonferroni） were used to analyze the difference among the rates, in order to evaluated the effect of the measures. Results The 24-hour file rates of discharged medical records were respectively 96.76%, 99.49%, 99.39% and 99.47% during June, October, November and December, 2014. The difference among the 4 rates was of statistically significance （ X2=198.2151, P〈0. 0001）, and the rates of October, November and December were all higher than that of June （The X2 values were 83.0866, 78. 9673 and 96. 3323, respectively, each of the P values was 〈0. 0001）. Conclusions The 24-hour file rates of discharged medical records were effectively improved by taking multiple measures, such as circulating a notice of criticism, detaining bonus and regularly reminding, which was a great progress for the hospital to avoid or eliminate medical records delay.