内蒙古某医联体110所二级医院病案质控现状调查

目的了解内蒙古自治区某医联体二级医院病案质控现状，为进一步规范病案管理工作提供参考。方法制定《病案管理及质量控制工作情况调查表》。定性资料采用频数和占比描述。结果共调查二级医院110所，平均编制床位与病案人员的配备比例为67.33:1。病案室属于独立科室的医院有22所，占20.00%。病案收集、病案整理、病案复印等工作开展比例较高，均＞80%。病案保存方式以纸质为主，占56.36%。对终末病案进行质控医院较多，对门诊病案开展质控医院较少。病案书写不及时、病案管理人员少、病案质检率未达到100%等是病案质量管理存在的主要问题。结论建议优化二级医院病案管理组织体系，完善病案室工作职能，增加病案管理人员配备，提高病案质量和管理水平，为医联体管理和运行奠定坚实基础。

Investigation on the Quality Control of Medical Records in 110 Hospitals of Medical Union in Inner Mongolia

ObjectiveTo investigate the status quo of medical record quality control in secondary hospitals of medical union in Inner Mongdia Autonomous, and to provide reference for further standardizing medical record management.MethodsThe questionnaire of medical record management and quality control was made. Qualitative data were described by frequency and proportion.ResultsA total of 110 secondary hospitals were investigated, and the average ratio of beds to case staff was 67.33 to 1. 22 hospitals, accounting for 20.00%, had independent medical records. The proportion of medical record collection, medical record photocopying and medical record collation was high, more than 80%. Medical records were mainly preserved on paper, accounting for 56.36%. The quality control of terminal medical records were carried out by more hospitals, but few hospitals carried out quality control of outpatient medical records. The main problems of medical record management were not timely writing, few medical record management personnel, and the quality inspection rate of medical record not reaching 100%. Conclusion It was suggested to optimize the organization system of medical record management in secondary hospitals, improve the function of medical record room, increase the number of medical record management personnel, improve the quality and management level of medical record, and lay a solid foundation for the management and operation of medical union.