病案信息数据构建在病案管理中的应用分析

Application Analysis of Medical Record Information Data Construction in Medical Record Management

目的探讨病案信息数据构建在病案管理中的应用价值。方法选取2021年1月—2022年12月淄博市妇幼保健院收治的住院患者1000份相关病案资料为调查分析对象。实施前后各抽取500份。另外参与病案管理工作人员均为50名。对照组实施常规非信息化病案管理,观察组则实施基于病案信息数据的构建下的病案管理。比较两组病案管理对象工作效率得分、病案利用情况,统计两组病案管理效率指标变化情况。结果观察组病历评级得分、病历书写质量得分和病历评级效率得分显著高于对照组,差异有统计学意义(P均<0.05)。观察组病案利用相关指标中的科研相关、教学相关、患者相关和医保管理相关等总利用度显著高于对照组,差异有统计学意义(P均<0.05)。观察组病案复印时间和病案调阅时间短于对照组,差异有统计学意义(P均<0.05)。结论实施基于病案信息数据的构建下的病案管理,对提高病历评级得分和病案管理效率有一定价值,另外还可提高病案利用度。

Objective To explore the application value of medical record information data construction in medical re-cord management.Methods From January 2021 to December 2022,1000 inpatients in Zibo Maternal and Child Health Hospital were selected as the investigation and analysis objects.500 were samples selected before and after implementation.In addition,there are 50 staff members involved in the management of medical records.The control group implemented routine non-information medical record management,and the observation group implemented medical record management based on the construction of medical record information data.The work efficiency scores and the utilization of medical records of the two groups were compared,and the changes of efficiency indexes of medi-cal records management in the two groups were analyzed.Results The medical record rating score,medical record writing quality score and medical record rating efficiency score in observation group were significantly higher than those in control group,and the differences were statistically significant(all P<0.05).The total utilization of relevant in-dicators of medical record utilization in the observation group was significantly higher than that in the control group,and the differences were statistically significant(all P<0.05).The time of copy and review of medical records in the ob-servation group was shorter than that in the control group,and the differences were statistically significant(both P<0.05).Conclusion The implementation of medical record management based on the construction of medical record in-formation data has certain value to improve the medical record rating score and the efficiency of medical record man-agement,and can also improve the utilization of medical records.