边疆医院病案复印情况分析

Analysis on the Medical Records Duplication Situation of a Borderland Hospital

统计对比分析边疆医院连续3年病案的复印数据,着眼医疗工作新形势和患者维权新需求,发现病案复印中存在患者对复印的认识存在偏差、证件携带不齐全、病案归档不及时、患者基本信息录入差错、病案管理人员业务能力不强、病案复印流程不尽合理等6个方面的问题。通过深入分析病案复印出现问题的原因,帮助医院人员进一步提升对病案管理重要性的认识,增强工作主动性和责任感。针对工作差距和素质隐忧,提出加强院内宣教、能力培训、规范管理、隐私保护等工作措施,及时纠改思想上、工作上、制度上存在的误区与粗疏,使服务态度更加端正,人员素质不断提高,工作流程得以优化,内涵建设逐步完善,在尊重患者合法权益的同时,把服务工作做细抓实,树立热情、周到、精细、规范的窗口形象,在提高医院整体建设质量与层次中发挥积极作用。

To conduct a statistical comparison on the duplication data of medical records in continuous three years of a borderland hospital, focus on the new situation of medical work and the rights protection requirements of the patients, we found many problems in the duplication of medical records, which mainly included six aspects such as deviation existing in their awareness of duplication, incomplete of certificates, late archiving of medical records,mistaken in the basic information of the patients, weak ability of the medical records management staff and unreasonable duplication process. Through analyzing the reasons emerged in the duplication process of medical records, we could help the hospital staff increase their awareness on the importance of medical records management deeply and strengthen their enthusiasm and responsibility. Aimed at the shortages existing in the work process and the quality of the staff, we put forward to take measures such as strengthen hospital propaganda and education,ability training, standardize management, protection of privacy. Therefore, we could correct the misunderstanding and careless in degree of thoughts, work and rules, and make the service attitude better, improve the quality of the staff, optimize the work process and complete the connotation construction gradually. We should formulate passion,considerate, careful and standardized image by accurate management of the service work as well as respect the civil rights of the patients, so as to play a positive role in the quality construction of the hospital entirely.