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目的通过对病案复印内容、用途、复印时限以及出院科别的构成分析,为病案管理、病案服务质量持续改进提供依据。方法检索2013年-2015年病案复印数据,进行回顾性分析,利用Excel整理和分析数据。结果出院病案105 708份,申请病案复印累计40 848人次,复印用途以保险报销和参考复查为主,占93.7%;复印前三项内容为出院小结、医嘱单、医学影像及化验单;出院患者病案复印率呈上升趋势,其中2月份复印例数最少、12月份复印例数最多;乳腺外科出院患者复印比例最高,达64.93%,儿内科、儿外科患者出院后复印及时性较高;患者出院当天要求复印的例数占全部的14.34%。结论结合病案复印统计分析结果,从病案复印的告知、预约申请、身份审核识别、排队管理、查询缴费、电子病案建设等方面改进病案复印流程,提高病案服务效率,持续改进病案服务质量,为患者提供良好的服务。
Objective To provide the basis for the continuous improvement of medical record management and medical record service quality through the analysis of the contents of the medical record copy, its usage, the time limit of copying and the composition of discharge department. Methods The data of medical records from 2013 to 2015 were retrieved and analyzed retrospectively. The data were sorted and analyzed by Excel. Results A total of 105 708 medical records were discharged and a total of 40 848 medical records were submitted for copying. Reimbursement was mainly based on insurance reimbursement and reference review, accounting for 93.7% of the total. Outpatient summary, doctor’s orders, medical imaging and laboratory test were the first three items for copying. The copy rate of medical records showed an upward trend, of which the number of photocopies was the lowest in February and the number of photocopies in December was the highest. The rate of copying was the highest in breast surgery patients (64.93%), and pediatric and pediatric patients The number of copies requested on the day accounted for 14.34% of all. Conclusion Combined with the results of the statistical analysis of medical record copy, the paper improves the medical record copy process from aspects of medical record copy, reservation application, identity verification and identification, queuing management, inquiry and payment, and electronic medical record construction to improve the efficiency of medical record service and continuously improve medical record service quality. Provide good service.