病案管理在老年慢性患者档案保存整理中的应用研究

A Study on the Application of Case Management in the Preservation and Organization of Elderly Chronic Patients'Records

目的探讨病案管理在老年慢性患者档案保存整理中的管理效果。方法选择2020年5月—2022年5月老年慢性患者档案892份,根据时间点分为对照组(446份,2020年5月—2021年5月,纳入档案管理者25名)和观察组(446份,2021年6月—2022年5月,纳入档案管理者22名)。对照组采用常规方法管理,观察组联合病案管理,比较两组管理质量、档案书写保存整理差错率、3日归档、编码情况及档案管理者管理水平。结果观察组病案管理质量高于对照组,差异有统计学意义(P<0.05);观察组干预3个月后患者的档案书写保存中填写不完整、大病历缺页、书写不规范、首页空项、协议书缺乏发生率低于对照组,差异有统计学意义(P<0.05);观察组病案管理3个月后3日归档率及编码准确率高于对照组,差异有统计学意义(P<0.05);观察组管理3个月后护理文书整理、档案资料整理、资料排序、上架顺序及封面填写评分高于对照组,差异有统计学意义(P<0.05)。结论病案管理用于老年慢性患者档案保存整理中,有助于提升管理质量,降低档案整理差错率,3日归档及编码正确率较高,能提升管理者综合管理水平。

Objective To explore the management effect of case management in the preservation and organization of elderly chronic patients'records.Methods 892 geriatric chronic patient files from May 2020 to May 2022 were selected and divided into a control group(446 files,May 2020 to May 2021,25 file managers were included)and an observation group(446 files,June 2021 to May 2022,22 file managers were included)according to time points.The control group was managed by conventional methods and the observation group by joint case management.The quality of management,the rate of errors in file writing and preservation and organization,3-day filing,coding and the level of file managers'management were compared between the two groups.Results The quality of case management in the observation group was higher than that in the control group,the difference was statistically significant(P<0.05).The incidence of incomplete filling,missing pages of major medical records,irregular writing,empty items on the first page,and lack of protocols in the file writing and preservation of patients in the observation group after 3 months of intervention was lower than that in the control group,the difference was statistically significant(P<0.05).The 3-day filing rate and coding accuracy rate were higher in the observation group than in the control group after 3 months of case management,the difference was statistically significant(P<0.05).The ratings of nursing paperwork organization,file data organization,data sorting,shelving order and cover filling were higher in the observation group than in the control group after 3 months of management,the difference was statistically significant(P<0.05).Conclusion Case management used in the preservation and organization of elderly chronic patients'files can help to improve the quality of management,reduce the rate of errors in file organization,and have a higher rate of correct 3-day filing and coding,which can improve the comprehensive management level of managers and is worth promoting the application.