目的了解青岛市109所医院病案科室的设置及病案管理现状。方法对青岛市109所医院的病案科室进行现场调查,资料采用SPSS17.0软件进行统计分析。结果设有住院病房的72所医院中,87.50%的医院设有病案科室;病案从业人员年龄结构以30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。在设有病案科室的63所医院中,53.97%的医院设有病案终末质控,病案终末质控率达到100%的医院有12所;有46.03%的医院配有编码专职人员,其中74%的编码专职人员取得了相应的专业资格。结论病案科室的设置及病案管理已日臻完善,但仍存在病案科室在医院地位偏低,专职人员数量不足,专职人员学历、专业、年龄结构不合理等诸多问题。 Objective To understand the setting of medical records department and medical record management in 109 hospitals in Qingdao. Methods A field investigation was conducted on the medical records of 109 hospitals in Qingdao City. The data were analyzed by SPSS17.0 software. Results Of the 72 hospitals with in-patient wards, 87.50% of them had medical records departments. The age structure of medical practitioners was mainly over 30 years of age. Their qualifications were mainly undergraduate and their nursing staff mainly focused on nursing and clinical medicine. Among the 63 hospitals that have medical records departments, 53.97% of the hospitals have end-of-life quality control and 12 of the hospitals have 100% of the end-of-life medical records. 46.03% of the hospitals have coded professional staffs, of which 74% of the full-time coding staff have obtained corresponding professional qualifications. Conclusion The establishment of medical records department and medical record management have been improved. However, there are still many problems such as the low status of medical records department in the hospital, the shortage of full-time staff, the academic qualifications of professional staff, the age structure and so on.