某县级医院2012年-2016年病案信息资源的利用

Utilization of Medical Records Information Resources of a County Level Hospital from 2012 to 2016

目的分析病案资料在临床医、教、研、管、防以及社会服务中的利用情况。方法提取某院2012年-2016年医务科、科教科、医院工作报表和病案使用登记簿中的相关数据,应用SPSS20.0统计软件对病案利用情况进行对比及线性趋势χ~2检验。结果院内利用率、院外利用率及两者合计的总体趋势均呈上升趋势(P均<0.05);院内利用情况中病案质控、重点专科、论文科研、晋升职称、教学、其它及全体合计均呈上升趋势(P<0.05);院外利用情况中保险公司及患者复印2个项目的上升趋势无显著意义(P均>0.05);而医保合并物价呈现下降趋势(P<0.05);公检法、其它及全体合计均呈上升趋势(P均<0.05)。结论病案信息资源在临床和社会服务中利用率逐年增加,医院管理者要打破病案管理重保管轻利用的现状,增强医务人员主动利用病案的意识和提高病案管理人员专业技能,促进病案信息资源的开发和利用。

Objective This paper analyzed the utilization of medical records information in clinical medicine, teaching, research, management, prevention and social services. Methods To collect statistic data about the utilization of medical record from 2012 to 2016, apply trend test to make comparison on the date of medical records utilization situation by SPSS20. 0 statistic software and Chi-square tendency. Results The number of using by hospital, the number of using by others and the total number including both all showed an upward trend （All the p 〈0. 05）. Among the using cases by hospital internal, including the medical records quality control, key specialty, paper research, title promotion, teaching, others and the total numbers were all rising（All the P〈0. 05）. Among the using cases from people out of hospital, the growing trend of copy numbers by insurance company and patients had no obvious significance （All the P〈0. 05）. The health insurance with goods price showed a downward trend （P〈0. 05）. The using numbers by public security organs and others were going up （All the P〈0. 05）. Conclusions The utilization rate of medical record information resources in clinical and social services was increasing year by year, the hospital managers should break the management of the current situation of emphasis on management and less attention on utilization, enhance the medical staff to take the initiative to use the awareness of medical records and improve the professional management of medical records, so as to promote the development and utilization of medical information resources.