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目的通过对医院病案归档现状的调查,找出病案延迟归档的原因,采取对应的措施,以提高出院病案归档率。方法随机抽取出院病案4051份计算病案归档率。结果普通出院病案三日归档率为51%,死亡病案七日归档率为20%。均未达到第四版《医疗护理操作技术常规》[1]的标准。结论医院应重视和加强病案归档工作,建立有效的病案归档管理制度和奖惩制度,实现病案归档程序化管理。
Objective To find out the reasons for the delayed archiving of medical records and to take corresponding measures to improve the archival rate of discharged medical records. Methods 4051 hospital cases were randomly selected to calculate the medical record rate. Results The general hospital discharge rate was 51% for the three-day case, and the death rate was 20% for the seven-day case. None of them met the standard of the fourth edition of “Technical Practices for Medical Care Operations”[1]. [Conclusion] Hospitals should pay attention to and strengthen the archiving of medical records, establish an effective medical records management system and rewards and punishments system, and realize the program management of medical records.