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目的通过对患者出院病案归档方法进行持续改进,从而提高临床科室出院病案归档率。方法根据2012年4月至2012年9月,2013年4月至2013年9月病案录入系统统计的各科患者出院病案归档时间和出院时间,来计算病案归档率,对延迟归档病案进行统计分析,提出改进措施。结果 2012年4月至9月出院病案4714份,2日归档率为81.5%,7日归档率为95.7%,采取改进措施后,2013年4月至2013年9月全院出院病案5557份,2日归档率为97.6%,7日归档率达99.9%。结论医院领导对病案管理的重视,健全完善的病案管理和奖惩机制,加强病案室与其它科室工作交流是提高归档率行之有效的措施。
Objective Through the continuous improvement of patient discharge record filing methods, so as to improve the clinical department filing rate of discharge cases. Methods According to the time of hospital discharge and the discharge time of patients in each department from April 2012 to September 2012, April 2013 to September 2013, the medical record filing rate was calculated and the data of delayed filing medical records were analyzed statistically , Proposed improvement measures. Results 4714 cases were discharged from April to September in 2012, the filing rate on the 2nd was 81.5% and the archiving rate was 95.7% on the 7th. After the improvement measures were taken, 5,557 cases were discharged from the hospital from April 2013 to September 2013, The filing rate on the 2nd was 97.6%, and the filing rate reached 99.9% on the 7th. Conclusion The leadership of the hospital attaches great importance to the medical record management, perfect the medical record management and rewards and punishments mechanism, and strengthening the work exchange between the medical record room and other departments is an effective measure to improve the filing rate.