德阳市129家医疗机构病案管理现状调查分析

Investigation and Analysis on the Current Status of Medical Record Management in 129 Medical Institutions in Deyang City

目的了解德阳市辖区内各医疗机构病案管理科工作现状,为推进全市病案管理科室科学化建设提供客观依据。方法2023年4月26日-5月21日采用问卷调查方法收集129家医疗机构病案科基本情况、人员配置、业务开展、信息化建设等内容,由各医疗机构实名填写病案管理专业基线调查表。建立数据库,进行描述性分析。结果129家医疗机构中72家医院病案科室隶属于医务科,占55.81%;30~39岁年龄段病案工作人员占38.18%,本科人员占54.13%,医学相关专业人员占51.00%;实际开放床位数与病案人员比为86.9:1,开展住院病案首页质控医院占89.15%,主要诊断编码正确率大于90%医院占79.84%;开展线上病案复印预约服务占5.43%,采用数字化扫描的医院仅占7.75%。结论德阳市部分医疗机构病案管理科室设置不合理,病案管理人员不足,专职人员学历、专业配备不合理,需进一步完善科室隶属,加强人员队伍建设,优化科室人员结构,提升业务能力,同时加强信息化建设,为现代化病案管理提供支撑。

Objectives This study aims to Understand the current status of medical record management departments in various medical institutions in Deyang City and provide an objective basis for promoting the scientific construction of medical record management departments in the city.Methods From April 26 to May 21,2023,a questionnaire survey was used to collect the basic information,personnel allocation,business development,information construction and other contents of the medical records department of 129 medical institutions.Each medical institution filled in the professional baseline survey form for medical record management with real name.Results Among the 129 medical institutions,72 medical record departments were subordinate to the medical department,accounting for 55.81%.Medical records staff aged 30-39 accounted for38.18%,undergraduate staff accounted for 54.13%,and medical related professionals accounted for 51.00%.The ratio of actual number of open beds to medical record personnel was 86.9:1.89.15%of hospitals carried out quality control on the front page of inpatient medical records.The accuracy rate of main diagnosis coding was greater than 90%in 79.84%of hospitals.5.43%of the respondents provided online medical record copying reservation services.Only 7.75%of hospitals used digital scanning.Conclusions The medical record management departments of some medical institutions in Deyang City are not set up properly.There are not enough medical record management personnel,and the education and professional configuration of full-time staff is not reasonable.These hospitals need to further improve department affiliation,strengthen personnel team building,optimize department personnel structure,improve business capabilities,and at the same time strengthen information construction to provide support for modern medical record management.