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目的了解目前山东省三级综合医院的病案科现状,为医院病案科建设提供依据。方法通过调查问卷形式向山东省三级综合医院病案科调查设置、隶属、人员配置、教育培训情况。结果山东省三级综合医院中13.79%病案科作为独立科室;所有三级综合医院病案科均不负责挂号工作;病案科工作人员男女比例1:4.76,年龄结构以40岁以上为主,学历以大学本科为主,人员专业以护理与临床医学为主;平均编制床位与病案管理人员的配备比例117.43:1;病案科每人每年参加继续教育0.25次。结论山东省三级综合医院病案科隶属关系混乱,病案科人员配比不合理,病案管理专业人员缺乏,医院编制床位与病案管理人员的配比不足,教育培训不足。
Objective To understand the current situation of the medical records department of the tertiary general hospitals in Shandong Province and provide the basis for the construction of the medical records department of the hospital. Methods Through the questionnaire survey to the Shandong Provincial General Hospital of three cases of medical records investigation set, membership, staffing, education and training. Results There were 13.79% of cases in the third grade general hospitals in Shandong Province as independent departments. All Grade III general hospitals were not responsible for registering cases. The ratio of male to female was 1: 4.76. The age structure was mainly for those over 40 years old. University undergraduate-based, professional staff to care and clinical medicine-based; the average preparation of beds and medical record management staffing ratio 117.43: 1; case record per person per year to participate in continuing education 0.25 times. Conclusion The affiliation of the department of illness and medicine of the level III general hospital in Shandong Province is chaotic. The proportion of staff in the department of medical record and casework is not reasonable, the number of medical record management professionals is lacking. The ratio between the hospital beds and medical records management staff is insufficient, and the education and training are inadequate.