强化病案管理的做法与实践意义分析

The Practice of Strengthening Medical Record Management and the Practice Significance

目的总结我院强化病案管理的做法,分析强化病案管理的实践意义。方法结合我院病案工作实际,设计强化病案管理策略,于2018年1月开始实施。随机抽取实施强化病案管理后的200份病案资料进行检查,以2017年12月的200份病案资料作为对照,统计强化病案管理前后的病案回收情况、出院病案排序情况、病案信息准确情况、出院病案装订及病案在架情况。结果实施强化病案管理后,强化组病案回收准确率、病案信息加工准确率、出院病案排序正确率、出院病案装订正确率、病案在架准确率高于常规组,差异具有统计学意义,P<0.05。结论开展强化病案管理有助于提高病案管理质量和工作水平,减少出错情况,对于完善病案管理体系、促进病案管理工作持续发展具有积极意义。

Objective To summarize our hospital to strengthen the practice of medical record management,analysis of the practical significance of strengthening medical record management.Methods Combining the reality of the hospital medical record work,designed to strengthen medical record management strategy,in January 2018.A random sample of 200 medical record after the implementation of strengthening medical record management information for inspection,in December 2017,200 copies of the medical record data as a comparison,statistics before and after strengthening medical record management of medical record collection situation and situation of the hospital medical record sorting,medical record information accurately,hospital medical record and medical record in the frame.Results After the implementation of strengthening medical record management,strengthen the group medical record collection accuracy,medical record information processing accuracy,the hospital medical record sorting accuracy,the hospital medical record binding accuracy,medical record in accuracy is significantly higher than normal group,P<0.05,with statistical significance.Conclusion To strengthen medical record management is helpful to improve the quality of medical record management and working level,reduce the error,to improve the medical record management system,promote the sustainable development of medical record management has positive significance.