摘要
目的探讨医院住院病案回收不及时的原因并提出对策,以便准确及时的将病案资料转化为医疗信息,提高医院综合管理水平。方法按照《江苏省三级综合医院评审标准实施细则(2012版)》第四章要求,使用《住院病案回归病案室情况考核表》对33个临床科室病案回收情况进行考核评价,统计学方法使用描述性统计。结果患者出院后2个工作日的病案回收率从2012年12月的70.8%上升到2015年7月的96.7%,平均提高率为25.9%,全院评价由最初的"D"不合格到现在的"B"良好状态。结论加强医院病案管理制度,使各科室主任逐步从过去的不过问到主动督促下级医师按时完成病案和催送病案。实行科主任考核是保障出院病案及时回收的有效措施。
Objective To investigate the causes of hospital medical record recovery not timely and put forward the countermeasures, in order to accurately and on time translate the medical records into medical information, and raise the level of hospital comprehensive management. Methods According to the chapter four of the third-class comprehensive hospital accreditation standards detailed rules for the implementation of Jiangsu Province（2012 edition）. Medical record recovery situation of 33 clinical departments was evaluated by medical record recovery evaluation forms and using descriptive statistics. Results The medical record recovery rate of 2 working days rose from 70.8% in December 2012 to 96.7% in July 2015. The average increase rate is 25.9%. Hospital-wide evaluation is from the original ＂D＂ is not qualified to ＂B＂ in good condition today. Conclusion To strengthen the hospital medical record management system, urge the department director supervise junior doctors finish medical record and rush to send medical record. The director inspection is an effective measure to guarantee hospital medical record timely recovery.
出处
《中国病案》
2016年第2期6-8,共3页
Chinese Medical Record
关键词
医院管理
病案回收
措施
Hospital management
Medical record recovery
Measures
