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目的通过分析某院住院病案复印数量、用途及科别构成,为完善医院的病案管理工作、提高医院质量管理水平提供依据。方法对某院2013年~2014年病案复印申请单进行回顾性研究和分析,采用Excel表格进行数据统计和分析。结果某院共出院患者85 144人次,复印病案6365例,复印的比率占7.5%。复印用途方面61.4%是为报销凭证,其次分别是办理社保慢性病卡、医学伤残等级鉴定、继续治疗资料留档、商业保险等。复印科别以普通外科(包括腹部外科、肝胆外科)、骨科、颅脑外科、妇产科为主。结论病案复印,使病案成为医院的一把双刃剑,医院必须提高质量管理水平,强化医务人员的法律意识和服务意识,严格执行《医疗机构病历管理规定》。
Objective To analyze the number, use and composition of inpatient medical records in a hospital so as to provide basis for perfecting the medical record management in hospitals and improving the quality management level in hospitals. Methods A retrospective study and analysis of a hospital photocopying application form from 2013 to 2014 was conducted, and the data were statistically analyzed with Excel. Results A total hospital outpatient 85 144 people, 6,367 cases of copying, copying accounted for 7.5%. 61.4% of copying purposes is for reimbursement of vouchers, followed by social security card for chronic disease, medical grade identification, continued treatment of data retention, commercial insurance. Copy department to general surgery (including abdominal surgery, hepatobiliary surgery), orthopedics, cranial surgery, obstetrics and gynecology based. Conclusion The medical record is duplicated, making the medical record a double-edged sword in the hospital. The hospital must improve the quality management level, strengthen the legal awareness and service awareness of the medical staff, and strictly enforce the Medical Records Management Regulations.