病案管理流程优化措施的实践探索

Practice and exploration of medical record management process optimization measures

目的:分析某院病案管理流程优化措施实施前后的效果,为优化病案管理提供依据。方法:对优化措施实施前后同期出院的病案管理流程进行回顾性分析,就病案回收时间、病案编码完成时间、5个工作日回收率、7个工作日编码完成率及病案首页合格率进行描述和统计分析。结果:优化措施实施后,病案回收时间和病案编码时间分别由优化措施实施前的(7.09±2.02)d和(8.71±3.27)d缩短为(5.60±2.00)d和(7.38±3.93)d,差异均有统计学意义(P<0.001);5日回收率、7日编码完成率和住院病案首页合格率分别由92.2%,77.2%和97.7%提高到了96.6%,90.3%和99.3%,差异均有统计学意义(P<0.001)。结论:病案管理流程优化措施可明显缩短回收时间,提高编码效率,改善病案首页质量,显著提升病案管理水平。

Objective:To analyze the effect of optimizing medical record management procedures in a hospital,providing data for optimizing medical record management.Methods:Compared the data of time from July to August 2019,when optimization measures were implemented,with the data from the same period in 2018,describing these indicators,such as archiving time of inpatient cases,the 5 working days filing rate of inpatient cases,the time for the completion of the case code,the 7 working days code completion rate,and the qualified rate of the first page of the medical record.Results:After the implementation of the optimization measures,archiving time of inpatient cases and the time for the com-pletion of the case code were shortened to(5.60±2.02)and(7.38±3.93)days from(7.09±2.02)and(8.71±3.27)days before the implementation of the optimization measures,and the difference was significant(P<0.001).The 5 working days filing rate of inpatient cases,the 7 working days code completion rate,and the qualified rate of the first page of the medical record also increased from 92.2%,77.2% and 97.7%to 96.6%,90.3% and 99.3% respectively,the differences were significant(P<0.001).Conclusion:The optimization measures of medical record management process significantly shorten the filing time,accelerated the recovery speed,improved the coding efficiency,improved the quality of the first page of medical record,and significantly enhance the level of medical record management.