北京市45家医院病案管理情况分析

Analysis on the Medical Record Management Situation in 45 Hospitals in Beijing

目的了解北京市45家医疗机构病案管理情况,发现问题与短板,以提高医疗机构病案管理水平。方法于2022年9月1日-2022年9月30日期间,使用调查问卷与北京市卫健委信息报告平台相结合的方式,调研北京地区医疗机构2019年1月1日-2021年12月31日期间病案管理情况。向199家医疗机构发放199份调查问卷,回收有效问卷149份,有效回收率为74.87%。为减小抽样造成的偏移,增加数据的连贯性和可比性,最终选取有连续3年有效数据的45家医疗机构数据进行分析。使用统计描述、卡方检验和配对t检验等方法,对包括科室职能、人员结构、质控项目、电子化进程等进行统计分析。结果病案科工作组设置数量逐渐上升,2021年平均为5.87组;百床位病案人员数波动在1.79人~2.15人之间;中、初级人员占比高达90%以上,且3年无优化迹象;人员专科学历占比达50%;开展门诊病案质控的三级医院占比不足50%;三级医院病案电子化进程快速推进,但二级医院发展相对迟缓。结论人员数量不足、高学历和高级职称人员比例较低,病案质控的范围仍需进一步外延,病案的电子化程度亟待进一步加强。

Objectives To understand the medical record management of 45 medical institutions in Beijing,and find the problems and weaknesses,so as to improve the level of medical record management.Methods During the period from September 1st,2022 to September 30th,2022,a combination of questionnaire and information report platform of Beijing Municipal Health and Health Commission was used to investigate the medical record management of medical institutions in Beijing area during the period from January 1st,2019 to December 31st,2021.199 questionnaires were distributed to 199 medical institutions,and 149 valid questionnaires were recovered,with an effective recovery rate of 74.87%.In order to reduce the deviation caused by sampling and increase the consistency and comparability of data,data from 45 medical institutions with valid data for 3 consecutive years were finally selected for analysis.Statistical description,Chi-square test and paired T-test were used to analyze the functions of departments,staff structure,quality control items and electronic process.Results The number of working groups in medical records department gradually increased,with an average of 5.87 in 2021.The number of medical records personnel in 100 beds fluctuated between 1.79 and 2.15,which was relatively reasonable.The proportion of middle and junior personnel was as high as 90%,and there is no sign of improvement in three years.The proportion of junior college education was 50%.Less than 50%of tertiary hospitals carried out quality control of outpatient medical records.The electronic process of medical records in tertiary hospitals was advancing rapidly,but in secondary hospitals is relatively slow.Conclusions At present,the functions of medical records departments in some medical institutions were continuously optimized and expanded,and the professionalism of medical records management was constantly enhanced.There were still problems such as insufficient number of personnel,low proportion of personnel with high education and senior titles.Meanwhile,the scope of medical record quality control still needed to be further extended,and the electronic degree of medical records needed to be further strengthened.