二级医院病案科室管理现状调查和分析

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目的二级医院病案科室管理长期未得到重视和关注。为加强二级医院病案科室管理,完善科室建设,北京市病案质量控制和改进中心(以下简称“病案质控中心”)开展全市部分二级医院病案科室管理现状调查工作。重点调查二级医院病案科室组织管理和规章制度、服务能力和病案资料安全。方法依据《医疗机构病历管理规定(2013年版)》和《二级综合医院评审标准(2012年版)实施细则》中的相关条款,病案质控中心组织专家制定相关调研表,对全市部分公立二级医院(含区域医疗中心)病案科室管理现状进行调查评价。查找科室管理不足,提出指导性建议及相应改进措施。结果调查的45家公立二级医院,有13家医院未将病案管理设置为科室;有34家医院规章制度、工作流程不完整;36家医院库房未达到安全要求;部分医院在科室服务能力,人员配置等方面均存在不同程度不足,应尽快依照相关要求加以改进和完善。使病案科室符合《二级综合医院评审标准(2012年版)实施细则》中的相关条款要求。 The purpose of secondary hospital medical records management has not been long attention and attention. In order to strengthen the management of the department of case management of secondary hospitals and improve the construction of departments, the investigation of the management of the case management of some secondary level hospitals in the city was carried out by the Beijing Municipal Center for Medical Records Quality Control and Improvement (hereinafter referred to as the “Quality Control Center for Disease Records”). Focus on investigating the second-class hospital medical records department organization and management and rules and regulations, service capacity and medical record data security. Methods Based on the relevant provisions in Regulations for the Management of Medical Records of Medical Institutions (2013 Edition) and the Criteria of Second-level General Hospital Accreditation Criteria (2012 Edition), the Center for Disease Control and Prevention organized experts to formulate relevant research forms, Hospital (including regional medical center) case management of the case management survey. Finding the lack of department management, make recommendations and corresponding improvement measures. Results The survey of 45 public secondary hospitals, 13 hospitals did not set the case management as a department; 34 hospitals rules and regulations, workflow is not complete; 36 hospitals did not meet the safety requirements; some hospitals in the service capacity, Staffing and other aspects of the existence of varying degrees of inadequate, should be in accordance with the relevant requirements to be improved and perfected. So that the case department in line with the “two General Hospital Accreditation Standards (2012 Edition) Regulations” in the relevant provisions of the requirements.
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