某市二级及以上公立医院病案科室建设和人员配置现状调查

Investigation on the Construction and Staffing of Medical Records Department in Public Hospitals of Level Two and Above in a City

目的 了解某市二级及以上公立医院病案科建设情况以及病案管理人员现状,为促进病案管理提供理论依据。方法 通过电子邮件对某市所有30家二级及以上公立医院开展问卷调查,并于2020年12月31日收集完毕,共回收27份问卷,调查内容包括病案科的科室设置、职能范畴、病案储存条件、病案信息化建设、人员配置情况等。结果 有48.15%的医院未独立设置病案科;病案科业务范畴主要集中于管理、质控、编码和统计方面,二级医院中缺失质控和编码职能的分别占26.09%和8.7%;85.19%的医院使用密集柜存放病案;37.04%的医院电子病历应用评级在3级以下;81.48%的医院存在不同程度的病案人员缺口;病案科从业人员学历以本科居多,所学专业以临床或护理学为主。结论 某市二级及以上公立医院中部分医院病案室隶属关系复杂,病历信息化程度低,病案从业人员缺员严重,专业人员数量少。医院管理者需要进一步重视病案科建设,加大病案信息化的投入,重视病案专业人才的引进与培养,不断拓展现代病案管理业务,使病案资源得到充分的开发和利用。

Objectives This study aims to investigate the construction and staffing of medical records department in public hospitals of level two and above in a city in order to provide theoretical basis for improving medical record management. Methods A questionnaire survey was conducted in all 30 public hospitals of secondary and above in a city through e-mail, and 27 questionnaires were collected until December 31, 2020.The investigation content included the department setting, service category, medical record storage conditions, medical record information construction and staffing. Results 48.15% of the hospitals did not set up an independent medical record department. The scope of services in medical record department mainly focused on management, quality control,coding and statistics. 26.09% and 8.70% of the secondary hospitals lacked quality control function and coding function respectively. 85.19% of the hospitals used high density filing cabinets to store medical records. 37.04% of the hospitals had application ratings of electronic medical records below level 3. 81.48% of the hospitals lacked medical record staffs in varying degrees. Most of the medical record practitioners had bachelor’s degrees, and their majors were mainly clinical or nursing. Conclusions Among the medical record department in all public hospitals of level two and above in this city, some have complex subordinate relationships, a low degree of medical record informatization, a huge shortage of employees and a lack of professionals. Hospital managers should pay more attention to the construction of medical record department, increase the investment in medical record informatization, focus on the recruiting and training of medical record professionals, and constantly expand the service of modern medical record management, so as to fully develop and make best use of the medical record resources.