绵阳市病案管理专业现状调查与分析

Investigation and Analysis of Current Situation of Medical Record Management Specialty in Mianyang City

目的了解绵阳市67家医疗机构病案管理现状,进一步科学化的规范绵阳市病案管理工作,提高绵阳市病案工作人员的专业水平。方法2019年6月1日-7月31日期间,采用调查问卷的方式向绵阳市67家医疗机构分发调查问卷,由各家医疗机构填写统一制定的病案管理及质量工作表。采用Microsoft OfficeExcel2019建立数据库,统计软件SPSS19.0进行数据处理。结果本次调查中病案科为独立科室的医院有43家,占调查总数的64.2%,病案科为二级科室的医院有24家,占调查总数的35.8%;病案科归分管院长直属的医院有15家,占调查总数的22.4%;归医务部分管的有23家,占调查总数的34.3%;归医教处分管的有6家,占调查总数的9%;归质控办分管的有3家,占调查总数的4.5%;归信息科分管的有16家,占调查总数的23.9%;隶属于其他部门的有4家,占调查总数的6%;三级公立医院病案管理人员床位比例最低,为1:109.5;绵阳市三级医院病案科开展统计工作的情况较好于二级医院;在绵阳市病案管理工作情况方面,二级医院与三级医院在门诊病历、院外其他培训类型、质控组开展情况及质控形式上的差异具有统计学意义。结论绵阳市病案管理专业趋近完善,但在信息化方面程度不够、二级医院病案科不受重视的情况仍然存在,且病案专业管理人才欠缺。

Objective To understand the current situation of medical records management in 67 medical institutions in Mianyang City,further standardize the medical record management in Mianyang City,and improve the professional level of medical record staff in Mianyang City.Methods From June 1 to July 31 in 2019,questionnaires were distributed to 67 medical institutions in Mianyang City,and all medical institutions filled in the unified medical record management and quality worksheet.Excel 2019 was used to establish the database,and the statistical software spss19.0 was used for data processing.Results In this survey,there are 43 hospitals with independent medical record department,accounting for 64.2% of the total survey;24 hospitals are secondary departments,accounting for 35.8% of the total;15 hospitals are directly under the charge of the president,accounting for 22.4% of the total survey;23 hospitals are under the management of the medical department,accounting for 34.3% of the total;6 hospitals are under the management of medical education,accounting for 9% of the total survey;and the quality is attributed to the quality There are 3 hospitals under the charge of the control office,accounting for 4.5% of the total survey;16 companies are under the charge of the information department,accounting for 23.9% of the total survey;4 companies are subordinate to other departments,accounting for 6% of the total survey;the proportion of beds of medical record management personnel in tertiary public hospitals is the lowest,with the ratio of 1:109.5;the statistical work of Medical Record Department of tertiary medical hospitals in Mianyang City is better than that of secondary hospitals;the medical record management work in Mianyang City is better In terms of the situation,the differences in outpatient medical records,other training types outside the hospital,the development of quality control group and quality control form between secondary hospitals and tertiary hospitals were statistically significant.Conclusion The major of medical record management in Mianyang City tends to be perfect,but the degree of informatization is not enough,the medical record department of secondary hospital is not paid attention to,and the medical record professional management personnel are lack.