纸质住院病案回收的强化管理

Strengthening Management of the Recovery of Paper Inpatient Medical Records

目的通过分析纸质住院病案回收管理中应用质量管理工具及相应管理方法的效果,探讨病案管理科学化的思路和举措。方法回顾2016年1月1日-2019年12月31日某三级综合医院109171份纸质住院病案回收情况动态变化,总结管理过程中多种质量管理工具及管理方法的应用情况。结果自2015年4月起针对纸质住院病案回收进行精细化管理,使用到查检表、品管圈、鱼骨图、柏拉图、PDCA等多种质量管理工具,24小时纸质住院病案回收率2016年较2015年改善最明显,24小时回收率提高13.38%,2017年与2016年对比无明显改善,深入分析并给予针对性干预措施后,2018年、2019年较上一年度回收情况改善较明显24小时回收率分别达到90.54%及93.43%。2015年至2019年病案回收情况整体呈明显改善趋势,24小时纸质住院病案回收由70.22%提升至93.43%,48小时纸质住院病案回收率由94.23%提升至99.71%。结论多种质量管理工具结合持续管理手段,有效改善纸质住院病案回收情况,推动病案管理科学化。

Objectives By analyzing the effect of applying quality management tools and corresponding management methods in the recovery management of medical records, to explore the strategies and measures for scientific management of medical records. Methods The dynamic changes of the recovery of medical records in a tertiary general hospital from 2016 to 2019 were reviewed, and the application of quality management tools and methods in the management process was described. Results The fine management measures on medical record recovery have been implemented since April 2015. The quality management tools such as check list, Quality Control Circle(QCC), fish bone map, Plato and PDCA-cycle were applied. 24-hour recovery rate in 2016 was 13.38% higher than the rate in 2015. Compared to 24-hour recovery rate in 2016, it got a similar result in 2017. The recovery rate of medical record improved in 2018 and in 2019 which reached to 90.54% and 93.43% separately. From 2015 to 2019, medical record returning status were obviously improved on the whole.24-hour of recovery rate increased from 70.22% to 93.43%, 48 recovery rate increased from 94.23% to 99.71%. Conclusions A variety of quality management tools combined with appropriate management methods could effectively improve medical records recovery status and promote the scientific management of medical records.