病案号管理的问题观察与处理对策

Problems of Medical Record Number Management and Countermeasures

目的对我院病案号管理的问题以及处理的对策进行讨论并深入分析,使得医院的病案管理水平能得到有效提高。方法随机选取2016年4月至2017年4月我院病案管理室四个科室各6份病历作为研究对象,对所有抽取病历进行检查,对病历进行记录,总结问题,对提出的问题进行探讨并提出解决方案。结果医师的责任心和法律意识不够强、病历的撰写不够规范、对病案管理的人员安排较少、技术相对落后、管理混乱、安全系数非常低的特点均为病案号管理中存在的问题。结论以建立健全病案质量监管体系、提高病案管理人员的综合素质、提高病案管理的安全性来加强病案管理能够取得较好效果。

Objective To discuss and analyze the problem of medical record number management in our hospital and make a deep analysis,so that the management level of medical record in hospital can be improved effectively.Methods Randomly selected from April 2016 to April 2017 medical record management in our room,6 copy each of the four departments records as the research object,from all check medical records,medical records for the record,summarizes the problems,discuss the issues raised and propose solutions.Results The writing of physician responsibility and legal awareness is not strong enough,the records is not standardized,on the medical record management personnel arrangement,less technology is relatively backward,management confusion,safety coefficient is very low for existing problems in the management of medical records.Conclusion In order to establish and improve the quality supervision system of medical records,to improve the comprehensive quality of medical record managers and to improve the safety of medical records management,the management of medical records can be enhanced and good results can be achieved.