2017年-2018年某三甲综合医院病案归档措施实施前后的效果分析

目的分析广东省惠州市某三甲综合医院病案归档措施实施前后的效果,探讨病案归档管理的有效实施方法和效果,为医院病案管理质量持续改进与提升提供依据。方法对2017年1月1日-2018年12月31日期间某院的172606份归档病案资料进行回顾性研究。将实施改进措施前的2017年的84459份归档病案,与实施一系列行之有效的改进措施后的2018年的87147份归档病案相互比较,对比结果进行整理、归类与统计分析。结果实施后的2日、3日、7日病案归档率为50.3%、67.0%、95.6%,实施前的病案归档率分别为31.9%、45.1%、86.8%,二者相比,差异具有统计学意义。其中实施后的第4季度7日病案归档率达到最高值97.4%。某院的病案归档管理的改进措施成效明显。结论某院在实施一系列整改措施后,优化病案归档全流程闭环管理,明显改善病案延迟归档现状,有效促进医院2日、3日、7日病案归档率明显提升,持续改进医院病案管理质量和水平。

Analysis on the Effect before and after The Implementation of the Medical Record Filing Measures in a Three A and Tertiary Hospital from 2017 to 2018

Objectives To explore the effective implementation methods and effects of the medical record filing management by analyzing the effect comparison before and after the implementation of the medical record filing measures in a Three A and Tertiary Hospital in Huizhou City,Guangdong Province,so as to provide the basis for the continuous improvement and improvement of the quality of the medical record management in the hospital.Methods A retrospective study was conducted on 172606 archived medical records of a hospital from January 1st 2017 to December 31st 2018.To compare 84459 filed medical records in 2017 before the implementation of improvement measures with 87147 filed medical records in 2018 after the implementation of a series of effective improvement measures,and collate,classify and statistically analyze the comparison results.Results The filing rate of 2,3 and 7 days after implementation were 50.3%,67.0% and 95.6%,and the filing rate of 2,3 and 7 days before implementation was 31.9%,45.1% and 86.8%,which was statistically significant.Among them,the filing rate of medical records in the seventh day of the fourth quarter after implementation reached the highest value of 97.4%.The improvement measures of medical record filing management in a hospital were effective.Conclusions After implementing a series of rectification measures,a hospital optimizes the closed-loop management of the whole process of medical record filing,significantly improves the status quo of delayed filing of medical records,effectively promoted the 2-day,3-day and 7-day medical record filing rate of the hospital to significantly improve the quality and level of medical record management in the hospital.