广西壮族自治区医院病案统计管理工作现状调查

Present Situation Investigation on the Medical Record Statistical Management in Hospitals of the Guangxi Zhuang Autonomous Region

目的了解广西各级医院病案统计管理现状及存在的主要问题和原因,为DRGs在广西的推行和广西病案统计管理的改进提供有力依据。方法于2016年3月以分层抽样、简单随机抽样和邮寄调查问卷的方法在全区各级医院抽选110家医院,回收94份,回收率85.45%,用SPSS10.0统计软件整理与分析。结果有79.78%的医院病案统计科由分管院长直接领导或由医务处(科)管理;90.43%、76.60%和55.32%的病案统计科负责ICD编码、医院信息统计和病案书写质量控制工作;病案统计专业技术人员平均7人,52.04%有编码培训合格证,21.65%有统计证,4.15%有质控培训合格证;三级医院病案统计人员参加学习培训比例达68.72%的;87.23%的医院实现电子病历,23.40%的医院实现病案部分无纸化。结论广西各级医院应重视医院病案统计科的学科建设,加强病案统计从业人员的培训和继续教育,提高编码准确率和统计分析能力,增强病案统计科实力和提高病案统计管理水平,为医院发展提供精准数据,提升医院管理能力。

Objectives To understand the present situation as well as the main problems and reasons of medical record statistical management in hospitals of the Guangxi Zhuang Autonomous Region, and provide powerful basis for the DRGs practice and the medical record statistical management improvement in Guangxi. Methods 110 hospitals were selected from hospitals at all levels of the region by stratified sampling and simple random sampling and mail questionnaire method in March 2016, 94 cases recycled, the rate was 85.45%, then conducted statistical analysis with SPSS10.0 software. Results 79.78% of hospital medical record statistical division led by the dean in charge of directly or by the medical department （section） management; 90. 43%, 76.60% and 55.32% of the medical record statistical department is responsible for the ICD coding, hospital information statistics and medical record writing quality control work. The average professional and technical personnel of medical record statistics was 7, 52.04% have an aptitude for coding, 21.65% had statistics, 4. 15% of quality certificate. The learning and training proportion was 68.72% in medical record statistical personnel of tertiary hospital, 87.23% of the hospitals realized electronic medical records and 23.40% of the hospital medical record realized paperless. Conclusions The hospitals in Guangxi at all levels should attach importance to the hospital medical record statistics of the discipline construction, to strengthen the medical record statistical personnel training and continuing education, improve the coding accuracy and statistical analysis ability, enhance the medical record statistical underlying strength and improve the management level of the medical record statistical and provide accurate data for hospital development, promote the management ability of the hospital.