调查分析医院病案管理中存在的问题及相应的解决措施

摘要

目的：调查并探讨医院的病案管理中所存在的问题，并对其解决的措施加以研究分析。方法选择我院的内科科室，调查科室的医务人员对于病案管理工作的重视情况及病案利用情况，选取2013年9月—2014年8月期间收治的51例患者，设为试验组，同时选取2012年9月—2013年8月期间收治的51例患者，设为对照组。该院自2013年9月开始实施病案管理措施，比较实施前后两组的病案质量的情况、患者的投诉率及患者的满意程度。结果试验组患者的病案质量的完善率（92.54%）、患者的满意程度（98.04%）均明显高于对照组患者的病案质量的完善率（61.76%）、患者的满意程度（72.55%），统计学均有意义（P＜0.05）；试验组患者的投诉率（1.96%）明显低于对照组患者的投诉率（27.45%），差异有统计学意义（P＜0.05）。结论实施有效的病案管理措施后，可以较大程度的提高病案质量的完善率、满足患者的期望值，使患者较为满意，应在临床上加以推广使用。%Objective To investigate and explore in the hospital medical records management problems and analyzed to study the measures to solve. Methods The medical department of our hospital, the investigation department of the medical staff's attention to the case management work situation and utilization of medical records, and from patients admitted to the department since September 2012 -2014 September period, 102 cases were randomly selected ,which were divided into a control group and the ex-perimental group two groups were 51 patients in the control group in September 2012 did not begin in September 2013 before the implementation of case management; experimental group in September 2013 -2014 case management measures implemented after September. Case, the rate of patient complaints and patient satisfaction were compared the quality of medical records. Results The medical records of patients with quality improvement rate of the test group (92.54%), the patient's degree (98.04%) were signifi-cantly higher satisfaction with the quality of the patient's medical records to improve the rate (61.76%), patient satisfaction (72.55%) statistical significance both (P<0.05); complaint rate (1.96%) patients with the experimental group was significantly lower than the complaint rate (27.45%) of patients in the control group, a statistically significant (P<0.05). Conclusion The implementa-tion of effective case management measures that can greatly improve the level of medical records to improve the quality rate, to meet the patient's expectations, so that patients are more satisfied, should be to promote the use in clinical practice.