分级诊疗制度的实施对三级医院病案质量管理影响与对策

Potential influence of hierarchical medical treatment system on management of medical records in Grade Ⅲ hospital and our countermeasures

病案文书是患者在住院期间医疗活动的原始记录,是综合评价医院医疗质量、技术和管理水平的重要依据。随着分级诊疗制度的逐步落实,三级综合性医院定位发生转变,着重对危重、疑难及复杂病例的诊治,对病案质量及其管理提出了严峻考验。本研究以上海交通大学医学院附属第九人民医院为例,收集其分级诊疗制度推行前后疑难危重患者占比等数据,结合医院出院病历质量检查中主要问题的变化情况,分析分级诊疗制度对三级综合性医院医疗结构调整及病案质量管理带来的影响,并探讨相应对策。

Medical records are the original records of medical activities during hospitalization,and also the basis for comprehensive evaluation of hospital medical quality,technology and management.With the implementation of the hierarchical medical system moving on in our country,the tertiary general hospital will gradually turn into a central institution mainly focusing on the diagnosis and treatment of critical,difficult and complicated cases,which may bring the acid test to the hospitals and also enhance the further importance of medical records management.Therefore,we preliminarily made a retrospective review of discharged case histories from Shanghai Ninth People’s hospital,compared the different proportions of patients and major problems of medical records before and after the implementation of hierarchical medical system as well.We presume the potential influence on management of medical records due to the hierarchical medical system,and also made some countermeasures probing.