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目的了解江西省病案管理发展30年来的状况。方法采用文献检索、资料收集、问卷调查等方法对江西省病案管理的机构设置、人员结构、信息化发展和工作内容方面进行回顾分析。结果 (1)县级以上医院均建立了病案科(室),并有16.92%(11/65)医院设有独立的病案科(室);(2)每机构平均病案管理人员由1.52人(108/71)增至3.89人(253/65)。中级及以上职称比例由18.52%(20/108)上升至68.38%(173/253);(3)病案信息化建设程度不一,个别医院实现了HIMSS双6评级;(4)病案工作重点在首页DRGs工作,质控重心移向环节管理。结论江西省病案管理工作逐步向规范化、内涵化、信息化和科学化发展。当前仍面临病案管理机构设置不尽合理、人员总体数量略显不足、病案首页填写有待完善、病案精细化以及信息化管理有待进一步提高。
Objective To understand the situation of the development of medical record management in Jiangxi Province for 30 years. Methods By means of literature search, data collection and questionnaire survey, the author made a retrospective analysis on the organizational structure, personnel structure, informatization development and work content of medical record management in Jiangxi Province. Results (1) The medical records department (room) was set up in all the hospitals above the county level, and 16.92% (11/65) of the hospitals had independent cases (rooms). (2) The average medical record management staff per organization was 1.52 108/71) to 3.89 (253/65). (3) the construction of informatization of medical records is different, and individual hospitals have achieved a double rating of HIMSS 6. (4) The focus of medical records is on Home DRGs work, quality control shift to link management. Conclusion The medical record management in Jiangxi Province has been gradually standardized, connoted, informatized and scientifically developed. Currently, the medical record management agencies are still not well-equipped and the overall number of staff members is slightly less. The first page of the medical record needs to be improved and the medical record management and information management needs to be further improved.