某市医疗机构病案管理现状调查分析

目的为全面了解某市医院病案管理水平,促进病案管理专业进一步发展和重视,为建设更专业化的病案管理队伍提供客观依据。方法2019年年初采用问卷调查法,以扫描二维码收集调查119家医疗机构2018年的数据,应用Excel 2010和SPSS20.0进行整理和分析。结果某市病案科(室)大部分隶属于医务科,占比47.06%,不同等级医院病案编码人员工作负荷不一致,病案管理人员的办公面积大部分在50平方米及以下,占比68.91%,61.34%的医院病案管理硬件设备勉强满足病案管理的日常运营,病案管理队伍中病案编码人员占比47.88%,其中75.66%的编码员持有编码证,39.32%的医院病案管理流程不完整,30.77%的医院病案归档不规范,66.67%的医院病案无法示踪,超过50.00%的医院历史病案还没有进行电子存档,出院病案3个工作日回收比例只有45.3%。结论某市医院病案管理专业重视程度有待进一步提高,病案管理人员专业水平参差不齐,不同级别医院管理水平差别显著,部分医院工作流程和方式还不规范,影响数据的准确性和可靠性。

Investigation and Analysis on the Current Situation of Medical Record Management in Medical Institutions in a City

Objective To comprehensively understand the level of medical record management in a hospital,promote the further development and emphasis of medical record management,and provide objective basis for the construction of a more professional medical record management team.Methods At the beginning of 2019,the questionnaire survey method was adopted to scan the Two-Dimensional code to collect the 2018 data of 119 medical institutions.Excel 2010 and SPSS20.0 were used for sorting and analysis.Results The medical record management department of a city is mostly subordinate to the medical department,accounting for 47.06%.The workload of medical record coders in different levels of hospitals is inconsistent.Most of the office space of medical record managers is 50 square meters or less,accounting for 68.91%.38.66%of hospital medical record management hardware and equipment barely meet the daily operation of medical record management.In the medical record management team,medical record coders account for 47.88%,among which 75.66%coders hold coding certificates.39.32%of hospital medical record management process is incomplete;30.77%of hospital medical records archiving is not standard;66.67%of hospital medical records could not be tracked;More than 50.00%of hospital historical medical records have not been electronically archived;Only 45.3%of discharged medical records were recovered within 3 working days.Conclusion The professional attention of medical record management in a city hospital needs to be further improved,and the professional level and management level of medical record management personnel are different,which will affect the accuracy and reliability of medical data.