住院病案归档与病案复印服务效率分析

Analysis on the Efficiency of Inpatient Records Archiving and Copying Service

目的调查与探讨住院病案复印服务中的病案归档时间现状与病案复印服务效率情况,为病案管理提供决策依据。方法采集定量研究与定性研究资料,定量研究资料包括2022年3月1日-2023年3月31日9128份某院系统中复印病案记录,结合某院住院患者出院2日后延迟归档的临床报告登记,采用例数、构成比等对采集到的数据进行统计描述分析;定性研究资料包括对某院医方和患方进行电话访谈,利用鱼骨图归纳病案复印服务的效率相关因素。结果某院9128份复印病案记录中,窗口病案复印量神经外科占31.75%、神经内科占23.47%、普通外科占6.52%、胸科占4.54%;邮寄复印量为神经外科占15.77%、神经内科占14.22%、普通外科占13.07%、胸科占8.16%;窗口复印以本省市本区外患者为主,占43.99%;邮寄复印外省市占44.04%、本省市外区占39.98%。9128份复印病案中,延迟归档检查检验报告的占8.38%;医嘱与检验检查报告不一致的占3.43%;信息不准确占复印病案的4.03%。经过鱼骨图分析,病案归档与复印效率主要有医师相关问题;护士相关问题;医技人员相关问题;特殊需求的病案;医疗管理相关问题;环境与物资相关问题;计算机相关问题;快递相关问题。结论科室病种、延迟归档、患者来源、管理流程等会影响病案复印服务效率;信息孤岛问题,没有互联互通,医嘱与报告项目不对应等也会影响服务效率。通过优化流程,提高归档病案中的电子归档文件占比,实现互联互通等现代化手段,与患者及家属、与医护技和相关部门有效沟通,以不断提高病案复印服务的效率。

Objectives To investigate and discuss the current situation of medical record filing time and the efficiency of medical record copying service in hospital medical record copying service,so as to provide decision-making basis for medical record management.Methods Quantitative and qualitative research data were collected.The quantitative research data included 9128 copies of medical records in the system of a hospital from March 1st,2022 to March 31st,2023,and combined with the clinical report registration records that were filed late 2 days after discharge of inpatients in a hospital,the collected data were statistically described and analyzed by case number and composition ratio.The qualitative research data included telephone interviews with doctors and patients in a hospital,and the factors related to the efficiency of medical record copying service were summarized by using fishbone charts.Results Among 9128 copies of medical records in a hospital,31.75%were in neurosurgery,23.47%in neurology,6.52%in general surgery and 4.54%in chest department.The number of copies sent by mail was 15.77%in neurosurgery,14.22%in neurology,13.07%in general surgery and 8.16%in thoracic surgery.Window copying was mainly carried out by patients outside the provinces and cities,accounting for 43.99%,mail copying outside the provinces and cities accounted for 44.04%,and outside the provinces and cities accounted for 39.98%.Among the 9128 copies of medical records,8.38%delayed filing of inspection reports;3.43%of patients had inconsistencies between medical advice and examination report.Information inaccuracy accounted for 4.03%of photocopied medical records.Through the analysis of fishbone chart,the efficiency of medical records archiving and copying were mainly related to doctors,nurse related issues,medical and technical personnel related issues,medical records with special needs,medical management related issues,environmental and material-related issues,computer related problems and express related issues.Conclusions The types of medical records,delayed filing,patient sources and management processes affected the efficiency of medical records copying service.Information island problems,lack of interconnection,medical orders and report items did not correspond to each other would also affect service efficiency.By optimizing the process,increasing the proportion of electronic archiving documents in medical records,realizing modern means such as interconnection,and effectively communicating with patients and their families,medical technology and relevant departments,the efficiency of medical records copying service was constantly improved.