武汉市三级医院病案科现状调查与分析

Investigation and Analysis of the Current Situation of Medical Records Department in Tertiary Hospitals in Wuhan

目的 了解武汉市三级医院病案科的建设现状,分析存在的问题并提出改进建议。方法 调查时间为2020年8月20日至2020年11月30日,采用问卷调查法,抽样调查了武汉市19家三级医院2019年的基本情况、病案科硬件建设及人员情况。结果 63.2%的样本医院病案科为独立的科室;73.7%自评所在地理位置便捷或较为便捷;42.1%自评资金投入充足或较充足;病案科平均办公面积153.16m^(2),人均面积12.7m^(2);79%阅览室的面积<25m^(2);73.7%对外接待室面积<20m^(2);68.8%常用病案存储面积小于500m^(2);57.9%无3年以上病案存储发展空间;病案人员平均14.21人,床位数/人员均值为143.6;编码人员平均5.3人,年人均工作量19590份。结论 武汉市三级医院病案科的重视程度和硬件建设水平有待提高;病案人员,尤其是编码人员不足,尚需加大人力投入。

Objectives To understand the status quo of the medical record department in tertiary hospitals in Wuhan,analyze the problems,and suggest improvements.Methods From August 20 th,2020 to November 30 th,2020,a sampling questionnaire survey method was used to survey the general condition,hardware construction and personnel of the medical record department in 19 tertiary hospitals in Wuhan in 2019.Results 63.2% of the medical record departments were independent departments,73.7% hospitals thought their location is in convenient or relatively convenient,and 42.1% thought their funding was sufficient or relatively sufficient.The average office area of the medical records department was 153.16 m~2,and the per capita area was 12.7 m~2,79% reading rooms area was less than 25 m~2,73.7% reception rooms area was less than 20 m~2,68.8% the medical records storage area was less than 500 m~2,and 57.9% of them did not have storage space for medical records for more than three years.The average medical record management staff was 14.21,and the average number of beds/person was 143.6,the average number of coders was 5.3,and the average annual workload was 19,590.Conclusions The attention to the medical record department and the hardware construction level in the tertiary hospitals in Wuhan needed to be improved,medical record personnel,especially coders,were insufficient,more manpower investment was needed.