某省二级医院病案管理现状调查和分析
马丽娟;陈珍初;黄后宝
【期刊名称】《中国病案》 【年(卷),期】2017(018)006
【摘要】目的 了解某省二级医院病案管理建设的现状,为加强二级医院病案科(室)建设提供依据.方法 采用问卷调查法于2016年5月3日-5月24日对某省内所有二级及以上医院进行调查,采用Epidata3.02软件进行数据录入,Microsoft Office Excel2007和SPSS19.0进行数据分析.结果 共收到185份二级医院的有效调查问卷.62.7%的二级医院病案科(室)隶属医院医务处;实际开放床位数与病案管理工作人员的平均配比为110.44:1;33.2%的病案管理工作人员为护理专业;45.12%的病案管理工作人员为高职/高专学历;147名专职病案质控工作人员,23.78%的二级医院的病案质检率为100%;32家医院没有疾病编码人员,31.46%的疾病编码人员通过省级ICD-10编码培训与考核.结论 加强病案科室管理需要厘清病案科的隶属关系,并配备相应的工作人员,病案工作人员应多途径提高自身素质和业务水平,采取系统化、流程化的病案质控管理办法,在全省范围内进行编码的技能培训.%Objectives To understand the current situation of medical record departments in the Two-level Hospital and offer the basis of strengthening medical record department construction of Two-level Hospital in our province.Methods Investigate all Two-level and above hospitals using questionnaires from May 3, 2016 to May 24. Perform data entry using Epidata 3.02 and analyze the data using Microsoft Office Excel2007 and SPSS19.0. Results 185 valid
questionnaires were received. 62.7% of the secondary hospital medical records attached to the hospital medical office; the average proportion of number of beds and medical record management staffwas110.44:1; 33.2% of medical record management staff's profession was nursing; 45.12% of medical record management staff' s education was vocational / college education; there were only 147 full-time medical record quality control staff; only 23.78% of the secondary hospital's rates of medical records quality control; there were 32 hospitals without disease coding staff; only 31.46% of the disease coding staff passed the provincial ICD-10 coding training and examination. Conclusion First of all, clarifying the affiliation of medical record department and providing some medical record staff; second, medical record staff should be strive to improve their quality and professional level by multi-channel; it's should take a systematic, process-oriented management approach to control medical records; finally, it is able to carry out coding training within the province.
【总页数】4页(3-6)
【关键词】病案管理;病案质控;疾病编码;二级医院 【作者】马丽娟;陈珍初;黄后宝
【作者单位】皖南医学院第一附属医院,芜湖市,241000;皖南医学院第一附属医院,芜湖市,241000;皖南医学院第一附属医院,芜湖市,241000 【正文语种】中文
【中图分类】 【文献来源】
https://www.zhangqiaokeyan.com/academic-journal-cn_chinese-medical-record_thesis/0201215063391.html 【相关文献】
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某省二级医院病案管理现状调查和分析
