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目的探讨病案利用价值的影响因素。方法统计分析医院2008～2009年病案利用情况,分析其影响因素,并实施相应干预对策。结果病案利用价值的主要影响因素依次为病案主要形成者、病案的利用者。实施干预措施后病案利用率明显提高(P<0.01)。结论通过加强医护人员病案书写规范培训、病案质控员及病案管理员专业培训、病案利用管理,能有效提高病案的利用价值。
Objective To explore the influencing factors of the use value of medical records. Methods Statistical analysis was conducted on the utilization of medical records in hospitals from 2008 to 2009. The influencing factors were analyzed and corresponding intervention strategies were implemented. Results The main influencing factors of the use value of medical records were the main form of the medical record and the users of the medical record. The utilization rate of medical records was significantly improved after the implementation of interventions (P<0.01). Conclusion By strengthening the training of medical personnel in the planning of medical records, the quality control of medical records, the professional training of patient management personnel, and the management of the use of medical records, the value of medical records can be effectively improved.