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目的通过对医院病案信息利用和管理情况的分析,探讨在新医改背景下如何开发和利用病案信息资源。方法收集医院2010年-2014年住院工作统计报表及病案室病案借阅登记和复印登记簿中病案利用的相关数据,应用SAS 9.2统计软件对病案利用情况进行对比及卡方趋势分析。结果随着出院患者的逐年增加,病案利用率也呈现逐年增长,由2010年的28.9%增长至2014年的32.82%,经卡方趋势检验P<0.0001,具有显著统计学差异;院内临床科研人员对病案的调阅利用情况也呈现逐年上升的趋势,从2010年的7205份增加至2014年11 200份,增长率为55.45%;院外医疗保险的病案利用从2010年的5715份增长至2014年的9534份,增长率为63.67%。结论病案在临床科研、医院管理以及医疗保险赔付等方面的利用率逐年增加,医院在病案管理方面应顺势而变,打破病案管理重保管轻利用的现状,提高病案管理的硬件配置,强化信息意识,提高服务效能,加强病案的信息化管理,促进病案信息的开发和利用。
Objective To analyze the utilization and management of medical record information in hospitals to explore how to develop and make use of medical record information resources under the background of new medical reform. Methods To collect the data of inpatient hospital work from 2010 to 2014 and the related data of medical record utilization in the medical records registration and copy register of medical record room, and to compare the use of medical record by SAS 9.2 statistical software and the chi-square trend analysis. Results With the increasing number of discharged patients, the utilization rate of medical records also increased year by year, from 28.9% in 2010 to 32.82% in 2014, with significant statistical difference by chi-square test (P <0.0001). The hospital clinical researchers The utilization of medical records also showed an upward trend year by year, from 7205 in 2010 to 11200 in 2014, an increase of 55.45%. The utilization of hospital medical insurance increased from 5715 in 2010 to 2014 Of the 9534 copies, an increase of 63.67%. Conclusion The utilization rates of medical records in clinical research, hospital management and medical insurance are increasing year by year. The hospital should take the advantage of the medical records management in order to break the current situation of medical records management, improve the hardware configuration of medical records management and strengthen the awareness of information , Improve service efficiency, strengthen the information management of medical records and promote the development and utilization of medical records information.