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目的分析某院出院病案24小时回收率,为进一步提高病案管理水平提供决策依据。方法基于某院办公信息系统公布的2014年6月、10月、11月、12月迟归病案信息和病案数字化综合管理系统提供的相应时段出院患者人次,按月计算出院病案24小时回收率。借助SAS 9.2软件,采用双向无序R×2表资料的χ2检验,并作两两比较(Bonferroni法),评价所采取措施的效果。结果 2014年6月、10月、11月、12月,出院病案24小时回收率依次为96.76%、99.49%、99.39%、99.47%。前后4个月的出院病案24小时回收率差异有统计学意义(χ2=198.2151,P<0.0001),且10月、11月、12月的出院病案24小时回收率都比6月份的高(χ2值依次为83.0866、78.9673、96.3323,P值均小于0.0001)。结论对出院病案迟归的临床科室、医护人员进行通报批评、扣发奖金、定期提醒,有效提高了出院病案24小时回收率,向杜绝病案迟归的目标迈近了一大步。
Objective To analyze the recovery rate of hospital discharge cases in 24 hours and provide decision-making basis for further improving the management level of medical records. Methods Based on the information of late-arriving medical records and the numbers of discharged patients provided by the medical records digital integrated management system in June, October, November and December 2014 published by the hospital’s office information system, the recovery rate of discharged medical records was calculated on a monthly basis. With the help of SAS 9.2 software, two-way disordered R × 2 table χ2 test and Bonferroni method were used to evaluate the effect of the measures taken. Results The recovery rates in 24 hours from June, October, November and December 2014 were 96.76%, 99.49%, 99.39% and 99.47% respectively. The recovery rate of discharged patients in 4 months before and after 4 hours was significantly different (χ2 = 198.2151, P <0.0001), and the recovery rate in 24 hours from October, November and December was higher than that in June (χ2 Values were 83.0866,78.9673,96.3323, P values were less than 0.0001). Conclusions The clinical departments and medical staffs who have discharged from hospital are informed of the criticism, deduction of bonuses and regular reminders, which effectively improves the 24-hour recovery rate of discharged patients and takes a big step towards eliminating the delay of medical cases.