某院心外科病案归档现状分析

Analysis on the Current Situation of the Filing of Cardiac Surgery Medical Records in a Hospital

目的通过回顾性对比分析某三级甲等综合医院心外科A病区的与其他4个心外科病区的病案迟归情况,分析影响病案迟归的因素,进而提高病案归档及时率。方法收集心外科病区2015年1月1日-2019年12月31日5年病案终末质量检查反馈单中病案迟归数据,同时采集期内出院患者人数、手术例数、实际开放床位数与在职医师人数等数据,运用Excel2000软件,采用百分率进行统计描述。结果2015年1月1日-2019年12月31日5年期内心外科A病区出院患者共计9744人次,手术9054例次,病案返修数共计3077份,返修率为31.6%,病案迟归数共计3550份,病案迟归率为36.4%。心外科A病区每年期内实际开放床位数最少,每张床位平均出院人次最多,最高为2015年90.9人次,最低为2019年57.1人次,病床周转快,医师人数少。结论增强临床科室全体人员对病案归档重要性的认识、适当增加住院医师的聘用和对护士整理病案的岗位及时调整、提高医护人员病案书写质量减少病案返修、优化病案信息系统提高个别检查报告单的回报速度、加强辅助科室间的沟通减少相关内容的缺失、落实病案奖惩到个人等是提高病案归档率的有效措施。

Objectives To analyze the delayed return of medical records between ward A of cardiac surgery department and other four wards of cardiac surgery department in Three A and Tertiary General hospital,analyze the factors affecting the delayed return of medical records,and improve the timely filing rate of medical records.Methods Late data of medical records were collected from the final quality inspection of the medical records in the department of Cardiac Surgery for 5 years from January 1st,2015 to December 31st,2019.At the same time,data including the number of discharged patients,the number of surgical cases,the actual number of open beds and the number of active physicians were collected.Results During the 5 years from January 1st,2015 to December 31st,2019,there were A total of 9744 patients discharged from ward A of cardiac surgery,9054 surgeries,2607 medical records were repaired,with A repair rate of 26.8%,3550 medical records were returned late,with A late recovery rate of 36.4%.The actual number of beds in Ward A of Cardiac Surgery was the lowest each year,and the average number of discharged patients per bed was the highest(90.9 person-time in 2015)and the lowest(57.1 person-time in 2019).The turnover of beds was fast,and the number of doctors was small.Conclusions To enhance clinical departments personnel about the importance of medical record archiving,proper increase of resident hiring and for nurses of medical record post timely adjust and improve the quality of medical staff medical record writing to reduce medical record repair,optimization of medical record information system to speed up the return of individual examination report,strengthen the communication between auxiliary departments to reduce the lack of the related content,the implementation of the medical record rewards and punishments to the individual was an effective measure to improve medical record filing rate.