病案示踪系统对病案回收质量的影响

The effect of Medical Records Tracking System on the quality of Medical Record Archiving

目的提高住院病案及时回收率,提升病案管理水平。方法开发应用病案示踪系统,利用掌上移动设备完成病案签收、交接、归档在病区内同步进行;通过系统自动实时生成统计报表及手机短信预警提高与临床科室沟通的效率和效果。结果使用出院病案示踪系统后与使用前相比,每月出院病案7个工作日回收率逐步上升,使用出院病案示踪系统的前3个月的平均出院病案7个工作日回收率为53%,而使用该系统后3个月的平均出院病案7个工作日回收率为77%,两者变化有统计学差异(P<0.05);临床科室对病案室满意度由使用系统前85%逐步上升到95%。结论病案示踪系统有效提高了住院病案回收归档质控水平。

Objective To increase the timely archiving rate of discharged medical records through the efforts of medical records tracking system. Methods Through the development and application of the medical records tracking system, the use of Personal Digital Assistant （PDA） on the scanning of the bar code on the first page of the medical records, the receipt, transfer and archive of the medical records were completed in the ward concurrently. The efficiency and effectiveness of communication between clinical departments and medical records department was improved by function of the real-time statistics and early warning by the short message platform. Results The 7-day timely archiving rate of discharged medical records increased from 53% to 95% （P〈0. 05）, the degree of the clinical department＇ s satisfaction to the medical record department increased from 85% to 95%. Conclusion Medical records tracking system can effectively improve the level of medical record management.