不同科室病案资料迟归原因分析

Analysis on the Status and Causes of Delayed-archived Medical Record Data between Different Departments

目的分析不同科室病案资料迟归的原因,并提出改进方法。方法通过2021年9月1日至2022年4月30日各科室迟归病案登记表,统计不同科室迟归病案资料的类型、数量及迟归天数,对迟归现状和原因进行分析。结果迟归病案资料总共7158页,出院人数为43353人,迟归病案资料总数/出院人数百分比为16.51%。其中百分比大于100%的科室有2个,百分比大于50%的科室有4个,内科迟归现象普遍比外科和骨科更严重。内科迟归项目主要为病理报告、化验单和影像报告。病理报告、影像报告、化验单、血液学报告的迟归数目最多、迟归天数较长。进一步对超长迟归(>100天)项目逐一回访发现:超长迟归项目的报告完成时间均小于30天,而归档时间远大于报告完成时间,由于其被遗忘或需要替换导致。结论内科相对其它科室病案迟归现象更加严重,以病理报告、检查报告等项目为主。针对此现象除要更加完善科室制度和实行奖罚措施外,还要杜绝因疏忽等问题导致的超长迟归病案资料的产生,从而促进病案的完整归档。

Objectives To analyze the situation and causes of incomplete archiving of medical record data in different departments,and propose improvement methods.Methods From September 1st,2021 to April 30th,2022,the single-page registration forms of late return records of each department were collected.According to the contents of the registration forms,the total number of single pages of late return and the contents of late return among different departments were counted,and the status and causes of late return were analyzed.SPSS17.0 statistical software was used for data analysis.Results The total number of the delayed-archived medical record single page was 7158,and the number of discharged patients was 43353.The percentage of total late return pages/discharged patients was 16.51%.Among them,there were two departments with a percentage greater than 100%and four departments with a percentage greater than 50%.In general,the phenomenon of late return in internal medicine was generally more serious than that in surgery and orthopedics.The contents of late return in internal medicine mainly focus on pathology report,laboratory report and imaging report.According to the statistics of major late return items,pathology report,imaging report,laboratory report and hematology report and the largest number of late return,and the number of days was longer.A further follow-up of the extremely long overdue(>100 days)projects found that the report completion time of the extremely long overdue projects was less than 30 days,and the filing time was much longer that the report completion time.The reasons for late return are:forgetting not timely archiving and some contents need to be replaced.Conclusion The medical record data of internal medicine department is more serious than that of other departments,especially the pathological report,examination report and other items are the most late.In view of this phenomenon,in addition to improve the department system and carry out reward and punishment measures,but also to eliminate the production of extremely long delayed single page caused by negligence and other problems,so as to promote the complete archiving of medical records.