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目的了解湖北省医疗机构的病案质量监管现状,为改善和提高全省病案科建设、建立健全病案质量监控体系以及考核评价机制提供依据。方法通过随机抽样法,对湖北省内69家各级医疗机构和医院的病案质量监管部门发放调查问卷,对病案质量监管部门的设置、人员配置、教育培训、病案质量监管方法及电子病案使用情况等进行调查。结果全省床位数与执业医师人数比为1:0.33,医院编制床位与病案专职管理人员的配备比例平均为175.23:1;病案质量管理人员组成中,病案科专职人员数平均为8.75人;三基培训、岗前培训以及针对病案书写的专题培训是最常见的培训方式,占据80%以上,但是频率较低;69家医院全部实现了病案书写电子化,58家医院采取了过程与终末质控相结合的监管方式。结论病案质量监管专业人员配比不足,病案书写培训频率低,尚未形成常态化。医院应注重病案质量管理队伍的建设,加强专业培训的力度,同时运用信息化手段形成环节质控与终末质控相结合的模式,完善电子平台系统,建立健全电子病历书写及流程管控。
Objective To understand the status quo of medical records quality supervision in medical institutions in Hubei Province, and to provide basis for improving and improving the construction of medical records in the province, establishing and perfecting medical records quality monitoring system and evaluation mechanism. Methods Through random sampling method, questionnaires were distributed to the medical record quality regulatory authorities in 69 medical institutions and hospitals in Hubei Province. The questionnaire was set up on the setting of medical record quality regulatory authorities, staffing, education and training, medical record quality supervision methods and the use of electronic medical records To investigate. Results The ratio of the number of beds in the province to the number of practicing doctors was 1: 0.33. The average preparation rate of hospital beds and full-time medical staffs was 175.23: 1. Among medical staffs, the average number of full-time medical staff was 8.75, Base training, pre-service training and special training on case writing were the most common training methods, accounting for more than 80% of the total, but at a lower frequency; all of the 69 hospitals had electronic medical records, and 58 hospitals took the process and the end Quality control a combination of regulatory approach. Conclusion There is not enough ratio of medical record quality supervision professionals and the training frequency of case record writing is low, which has not yet become normalized. The hospital should pay attention to the construction of the medical records quality management team and strengthen the training of professional staff. At the same time, the hospital should use information technology to form a combination of quality control and final quality control. The electronic platform system should be improved and the electronic medical record writing and process control should be established and perfected.