医院新职工对病案信息知识的认知调查

Investigation on the Cognition of Hospital’s New Staff on Medical Record Information Knowledge

目的调查医院新职工对病案信息知识认知现状,为做好新职工岗前培训中病案信息知识的课程优化提供基础。方法通过网络开展问卷调查,采用自制《病案信息知识认知调查问卷》,对上海市某三级甲等专科医院2020年1月1日-7月31日入职的70名新职工在医院统一举办的集中岗前培训期间进行认知现状调查。结果新职工对病案信息知识的认知度普遍较低,对其中患者隐私保护规定了解度相对最高,为57.4%,对ICD编码、DRGs和病案管理部门业务内容的了解度最低,分别为24.6%、11.5%、14.8%。不同性别、不同职务、不同学历新职工的认知状况差异无统计学意义。以往是否参加过病案信息知识培训为新职工认知状况差异的独立影响因素。结论新职工对病案信息知识的总体认识不高,应科学设置培训内容的结构,增加ICD编码和DRGs原理等模块,优化培训模式,以提高岗前培训的效率,为医院病案信息管理和利用奠定良好基础。

Objectives To investigate the current situation of new staff’s cognition of medical record information knowledge,so as to provide the basis for the course optimization of medical record information knowledge in the pre-job training of new staff.Methods During the centralized pre-job training of new staff,a self-made questionnaire on knowledge cognition of medical record information was used to investigate the cognitive status of 70 new staff from January 1st to July 31st,2020 in a specialized hospital in Shanghai.Results The knowledge of medical record information of new staff was generally low.The awareness of patients’privacy protection regulations was the highest(57.4%).The awareness of ICD code,DRGs and business content of medical record management department was the lowest,and was 24.6%,11.5%and 14.8%respectively.There was no significant difference in the cognitive status of new staff with different gender,position and education background.Whether having participated in any training of medical record information knowledge was the independent influencing factor of cognitive status of new staff.Conclusions It was urgent to increase the content of medical record information knowledge in the new staff pre-job training.We should scientifically set up the structure of training content,optimize the training mode,add modules such as ICD code and DRGs principle so as to improve the effect of induction training and lay a good foundation for the management and utilization of hospital medical record information.