江苏省某院病案归档现状及影响因素分析

Analysis on the Current Situation and Influencing Factors of Medical Record Filing in a Hospital in Jiangsu Province

目的通过分析江苏省某院临床科室出院病案归档现状,找出影响病案归档的影响因素,进一步提高病案归档率。方法根据2018年1月1日-2018年12月31日某院病案系统统计的全院各科室患者出院时间和归档时间,计算病案归档率,通过头脑风暴法找出影响病案延迟归档的影响因素,分析影响病案归档率的影响因素。结果 病案总体平均归档率为96.72%,3日病案平均归档数为(2603.0±46.2)份,7日病案平均归档数(2656.17±10.3)份。其中,7日归档率平均为97.68%,要好于3日归档率(95.75%)。影响病案归档率的因素为每日出院人数(t=99.36,P=0.005)、不同科室(t=53.36,P=0.001)、是否转科(t=10.23,P<0.001)和信息系统失误(t=9.36,P<0.001)。其中,每日出院人次大于10人、外科、有转科记录是导致病案延迟归档的主要原因(均P<0.05)。结论 医院要重视病案管理,合理配置医护人员比率,建立健全病案归档制度,加强信息化管理,从而进一步提高病案归档率。

Objective To find out the influencing factors of medical record filing and further improve the rate of medical record filing by analyzing the status quo of medical record filing in each clinical department of a hospital in Jiangsu Province.Methods According to the discharge time and filing time of medical records of all departments in a medical record system of Jiangsu Province from January 1 st to December 31 st 2018,to calculate the filing rate of medical records,find out the influencing factors of delayed filing of medical records through brainstorming,and further improve the filing rate of medical records.Results The overall average filing rate of medical records was96.72%,the average number of 3-day medical records was(2603.0±46.2),the average number of 7-day medical records was(2656.17±10.3),the 7-day filing rate 97.68%was better than the 3-day filing rate 95.75%.The factors that affected the late filing rate of medical records were the number of discharged patients per day,different departments,whether to transfer departments and information system errors.Among them,the main reasons for the delayed filing of medical records were more than 10 discharged persons per day,general surgery and transfer records(P<0.05).Conclusions The hospital should pay attention to the medical record management,reasonably allocate the ratio of medical staff,establish and perfect the medical record filing system,strengthen the information management,so as to further improve the medical record filing rate.