病案回收延迟的应对

Delay of Medical Record Recovery and Relevant Countermeasures

目的探讨病案回收工作流程,提高病案回收效率,发挥病案信息效用。方法 2019年1月1日-12月31日各科病案回收登记表,计算上半年全院月出院病案2日归档率,对回收延迟原因进行分析,同时计算下半年干预后出院病案2日归档率。采用SPSS统计软件将上下半年归档率进行对比分析。结果上半年回收病案总数为47625份,2日内回收病案43 291份,全院出院病案2日归档率在89.2%~93.3%之间,均值为90.9%,归档率趋势图呈逐月上升趋势,上半年影响病案回收的原因主要是书写、签字、完善不及时;病理结果归档不及时;病案回收环节待优化等。下半年回收病案总数为48 422份,2日内回收病案46582份,全院月出院病案2日归档率在95.2%~97.7%之间,均值为96.2%,月归档率趋势图9月较8月略微下降,11月较10月略微下降,但总体呈上升趋势。统计比较2组回收率具有显著性差异。结论合理配置医务人员、完善监管制度、全面提高医务人员职业素养和优化病案回收环节等措施可以显著提高病案回收效率。

Objectives Toexplore the work flow of medical record recovery, improve the efficiency of medical record recovery, and make full use of medical record information.Methods From January 1 st, 2019 to June 30 th, 2019, the medical records recovery registration form of each department in a hospital was retrieved, the two-day filing rate of the hospital’s monthly discharged medical records in the first half of the year was calculated, and a discussion meeting was held to analyze the filing data of the first half of the year and the reasons for the delay in recovery. From July 2019, after reasonable allocation of medical personnel, improvement of supervision system, overall improvement of professional quality of medical personnel and optimization of medical record recovery, the medical record recovery registration form of each department from July 1 st to December 31 st, 2019 was transferred, and the filing rate of the medical record discharged from the hospital in the second half of the year was calculated. SPSS software was used to compare the filing rate in the first half and the second half of the year.Results In the first half of the year, 47625 medical records were recovered, and 43291 medical records were recovered within two days. The two-day filing rate of the hospital’s monthly discharged medical records was between 89.2% and 93.3%, with an average of 90.9%. The trend chart of the monthly filing rate showed a rising trend month by month. It was found that the main reasons affecting the recovery of medical records in the first half of the year were that the writing, signing and improvement were not timely;the filing of pathological results was not timely;the recovery process of medical records needed to be optimized, etc. In the second half of the year, 48422 medical records were recovered, and 46582 medical records were recovered within two days. The two-day filing rate of the hospital’s monthly discharged medical records ranged from 95.2% to 97.7%, with an average of 96.2%. The trend chart of monthly filing rate slightly decreased in September compared with August, slightly decreased in November compared with October, but showed an overall upward trend. There was significant difference between the two groups.Conclusions Measures such as rational allocation of medical personnel, improvement of the supervision system, comprehensive improvement of medical personnel’s professional qualities, and optimization of medical record recovery links could significantly improve medical record recovery efficiency.