多民族边疆地区病案复印情况的分析

Analysis on the Medical Record Duplication Situation in Frontier Multi-ethnic Regions

目的分析边疆多民族地区病案复印中存在的问题,改善病案复印流程,提高病案复印的质量、速度及准确性。方法针对2014年-2016年多民族边疆地区某三甲医院病案资料登记表的数据进行回顾性分析。结果逐步完善病案复印的各项管理后,病案复印人数从2014年的48 238例增加到2016年的76 871例,增长率159.36%,并且病案复印的一次成功率从2014年的72.52%(34 982例/48 238例),提高到2016年的97.07%(74 615例/76 871例)。结论由于患者证件不齐、工作人员复印内容不全、病案未能提供及复印技术问题等原因导致病案复印的一次成功率较低,通过加大多种语言形式宣传及服务技能培训力度、优化复印流程等措施,提高病案复印的准确性及速度。

Objectives To analyze the problems in the medical records duplication in frontier multi-ethnic regions improve medical records duplication process, enhance the quality, speed and accuracy of medical records duplication. Methods To conduct a retrospective analysis on the data of medical records registration form in a Three A and Tertiary Hospital in frontier multi-ethnic regions from 2014 to 2016. Results After the gradually improvement of medical records duplication management, the duplication number increased from 48238 cases in 2014 to 76871 cases in 2016, the increasing rate was 159.36%, and the one time success rate of medical record duplication was increased from 72.52% （34982/48238） in 2014 up to 97.07% （74615/76871） in 2016. Conclusions Due to the lack of patient documentation, incomplete staff copying,, failure to provide the medical record and the technical problems of reproduction, one time success rate of reproduction measures such as enhancing the propaganda of multiple languages of the medical record was low. We should take and service skills training, optimizing duplication process measures, so as to improve the accuracy and speed of medical records duplication.