住院病案归档现状分析与持续改进

目的 通过对患者出院病案归档方法进行持续改进,从而提高临床科室出院病案归档率.方法 根据2012年4月至2012年9月,2013年4月至2013年9月病案录入系统统计的各科患者出院病案归档时间和出院时间,来计算病案归档率,对延迟归档病案进行统计分析,提出改进措施.结果 2012年4月至9月出院病案4714份,2日归档率为81.5％,7日归档率为95.7％,采取改进措施后,2013年4月至2013年9月全院出院病案5557份,2日归档率为97.6％,7日归档率达99.9％.结论医院领导对病案管理的重视,健全完善的病案管理和奖惩机制,加强病案室与其它科室工作交流是提高归档率行之有效的措施.

Current Situation Analysis and Continuous Improvement of Medical Record Archiving

Objective To improve the medical record archiving rate of hospital clinical departments by continuous improvement of patients discharged medical record archiving. Methods To calculate the rate of archiving, analyze the delay medical records and put forward the improvement measures according to the archiving time and discharge time in medical record entry system during April 2012 and September 2012, April 2013 and September 2013. Results After the improvement measures,2 days archiving rate was 97.6%, 7 days archiving rate reached 99.9% from 2013 April to 2013 September. Conclusion The hospital leadership should attaches great importance to the management of medical records, and improve medical record management and incentive mechanism, strengthen the work communication between medical record department and other departments to imorove archiving rate.