某省77家三级综合医院病案管理与持续改进

Medical Records Management and Continuous Improvement of a Tertiary General Hospital of a Province

目的分析三级医院评审中发现的病案管理工作中存在的不足,探讨提高病案管理工作的方法。方法分析某省2013年-2017年期间77家三级综合医院等级评审结果中"病历(案)管理与持续改进"16个条款的得分情况,利用帕累托图分析法找出主要不合格项目,并深入探讨存在的问题。结果评审条款中27.2.4、27.2.3、27.7.2、27.1.1、27.1.2、27.3.1这6个条款的不合格数累计构成比为77.05%,为主要不合格项目。主要内容集中在住院病案首页填写、电子病历的建设、病案科人员梯队配备、病案管理工作制度落实情况等方面。结论通过完善病案科人员梯队配备,注重相关规范制度的培训及落实,加强电子病历规范化建设,持续改进病案管理水平。

Objectives To analyze the deficiencies which were fund in the review of medical records management and explore the methods of how to improve it. Methods To analyze the score of 16 clauses of 'Medical Record(Case)Management and Continuous Improvement' in the grade assessment results of 77 tertiary general hospitals in a province from 2013 to 2017. Results The cumulative component ratio of the six items in the evaluation clauses(27.2.4, 27.2.3, 27.7.2, 27.1.1, 27.1.2 and 27.3.1) was 77.05%, between 0% and 80%, and they were the unqualified items. The main content focuses on writing of medical record front page, the construction of electronic medical records, the echelon construction of personnel in medical records department, and the implementation of the regime of medical records management. Conclusions It was very important to keep an eye on the training and implementing of relevant regime by improving the quality of staffs in medical record department.Meanwhile, the construction of standardized medical records should be strengthened, and the quality of medical records management should be improved.