论文部分内容阅读
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。
Objective To understand the current situation of the construction of medical records in secondary hospitals in a province and provide the basis for strengthening the construction of medical records (rooms) in secondary hospitals. Methods A questionnaire survey was conducted on all hospitals in the province from May 3 to May 24, 2016. Epidata 3.02 software was used for data entry, and Microsoft Office Excel 2007 and SPSS 19.0 were used for data analysis. A total of 185 valid secondary questionnaires were received. 62.7% of the second-grade hospital medical records department (room) belongs to the hospital medical department; the actual number of open beds and medical records management staff average ratio of 110.44: 1; 33.2% of medical record management staff for the nursing profession; 45.12% The staff members are vocational / technical college graduates; 147 full-time medical record quality control staffs, 23.78% of second-class hospitals have 100% medical records; 32 hospitals have no disease coders and 31.46% of disease coders pass provincial Level ICD-10 coding training and assessment. Conclusion It is necessary to clarify the affiliation of medical records department and strengthen the management of the medical records department. Equipped with the corresponding staff, the medical staff should improve their quality and professional level in many ways, adopt a systematic and procedural medical record quality control management approach, Coding skills training.