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目的探讨医院住院病案回收不及时的原因并提出对策,以便准确及时的将病案资料转化为医疗信息,提高医院综合管理水平。方法按照《江苏省三级综合医院评审标准实施细则(2012版)》第四章要求,使用《住院病案回归病案室情况考核表》对33个临床科室病案回收情况进行考核评价,统计学方法使用描述性统计。结果患者出院后2个工作日的病案回收率从2012年12月的70.8%上升到2015年7月的96.7%,平均提高率为25.9%,全院评价由最初的“D”不合格到现在的“B”良好状态。结论加强医院病案管理制度,使各科室主任逐步从过去的不过问到主动督促下级医师按时完成病案和催送病案。实行科主任考核是保障出院病案及时回收的有效措施。
Objective To investigate the reason why hospitalized medical records are not timely collected and put forward countermeasures so that medical records can be translated into medical information accurately and timely, and the comprehensive management level of hospital can be improved. Methods In accordance with the requirements of Chapter 4 of the 2012 Jiangsu Provincial Third Hospital General Accreditation Criteria (2012 Edition), the evaluation of medical records recovery in 33 clinical departments was conducted by using the “Assessment Form of Regression Cases of Inpatient Medical Records”. The statistical methods were used Descriptive statistics. Results The patients’ recovery rate increased from 70.8% in December 2012 to 96.7% in July 2015 with an average rate of 25.9% after 2 days of discharge. The hospital evaluation was initially rejected as “D” To the present “B ” good condition. Conclusion The hospital medical record management system should be strengthened so that the department directors gradually step from the past to the initiative to urge the subordinate physicians to complete the medical records and send medical records on time. The implementation of section chief examination is to ensure the timely recovery of discharged cases of effective measures.