某三级专科医院病案管理现状调查与分析

目的研究某三级专科医院病案管理现状,分析三级医院评审过程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2018年1月1日至2018年12月31日三级专科医院—阜外华中心血管病医院等级评审中“病历(案)管理与持续改进”16个条款的得分情况,通过根本原因分析法(RCA)对影响病案管理现状的原因进行系统分析,并深入探讨存在的问题。结果根据16项基本条款评审结果,A级病历占18.00%(108/600),B级病历占65.00%(390/600),C级病历占94.00%(564/600),D级病历占6.00%(36/600)。评审条款中,4.21.2.5、4.21.2.4、4.21.4.2、4.21.7.1、4.21.7.2、4.21.2.2、4.21.1.2这7个条款的不合格数较多,累计构成比达到81.68%,为主要不合格项目。影响病案管理现状的主要原因集中在病案首页填写、电子病历建立与维护、病案管理制度落实及病案人员培训与教育方面。结论通过加强电子病历维护和规范化建设,注重相关科室制度的培训和落实,加强病案管理人员专业素质提升,能有效改进我院病案管理水平。

Investigation and analysis of current situation of medical record management in a tertiary specialized hospital

Objective To study the current situation of medical record management in a tertiary hospital,analyze the shortcomings of medical record management found in the evaluation process of tertiary hospital,and probe into the methods of improving medical record management.Methods The scores of 16 items of"medical record(case)management and continuous improvement"in the grade evaluation of Fuwai central China cardiovascular hospital-a tertiary specialized hospital from January 1,2018 to December 31,2018 were analyzed.Root cause analysis(RCA)was used to systematically analyze the reasons that affect the current situation of medical record management,and the existing problems was explored.Results According to the review results of 16 basic terms,grade A medical records accounted for 18.00%(108/600),grade B medical records accounted for 65.00%(390/600),grade C medical records accounted for 94.00%(564/600),and grade D medical records accounted for 6.00%(36/600).Among the evaluation terms,there were more unqualified items in 4.21.2.5,4.21.2.4,4.21.4.2,4.21.7.1,4.21.7.2,4.21.2.2 and 4.21.1.2,and the cumulative constituent ratio reached 81.68%,which was the main unqualified items.The main reasons that affected the current situation of medical record management were mainly in the filling of the first page of medical record,the establishment and maintenance of electronic medical record,the implementation of medical record management system and the training and education of medical record personnel.Conclusion The medical record management level of our hospital can be effectively improved by strengthening the maintenance and standardization of electronic medical records,paying attention to the training and implementation of relevant departments,and enhancing the professional quality of medical record management personnel.