成都市709家医疗机构病案管理现状分析

Analysis on the Current Situation of Medical Record Management in 709 Medical Institutions in Chengdu

目的了解成都市病案管理现状,为推进病案学科建设提供可靠依据。方法2022年4月1日-2022年6月1日,对成都市709家医疗机构病案科(室)的设置、人员配备、科研与继续教育等工作开展实名制电子问卷调查。结果调查709家医疗机构中,病案科为独立科室67家,占9.45%,实际开放床位数与病案人员配备比99.4:1,临床、护理等医学相关专业占54.73%,初级及以下职称人员占67.82%,开展终末病案质控的医院85.75%,运行病历质控占74.75%;电子病历应用水平参差不齐,数字化扫描病案保存占9.9%。结论成都市医疗机构病案科设置有待完善,人员和科研水平不足,门急诊和环节病历质控力度不足,信息化成都需加强。建议合理规划病案的学科建设,优化人力资源配置,推进病案精细化管理,提升信息化建设,不断满足现代管理对病案的工作要求。

Objectives This study aims to understand the current situation of medical record management in Chengdu and provide a reliable basis for promoting the construction of the medical record discipline.Methods From April 1,2022 to June 1,2022,a real-name electronic questionnaire survey was conducted on the setting,staffing,scientific research,and continuing education of medical record departments in 709 medical institutions in Chengdu.Results Among 709 medical institutions,67 were independent departments,accounting for 9.45%.The ratio of the actual number of open beds to medical record staffing was 99.4:1.54.73%were clinical,nursing,and other medical-related majors,67.82%were junior professional title personnel,and 85.75%carried out the quality control of final medical records.Quality control of operating medical records accounted for 74.75%.The application level of electronic medical records was uneven,and digital scanning medical record preservation accounted for 9.90%.Conclusions The setting of the medical record department in Chengdu medical institutions needs to be improved.The level of personnel and scientific research is insufficient.The quality control of medical records in outpatient and emergency departments and links is insufficient.It needs to be strengthened in Chengdu.It Is suggested to reasonably plan the discipline construction of medical records,optimize the allocation of human resources,promote the fine management of medical records,improve the information construction,and constantly meet the requirements of modern management of medical records.