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目的分析精神疾病病案复印用途,促进精神专科医院病案质量的改进与提高。方法收集医院2007年-2010年度报表及精神疾病病案复印资料,统计年度出院人次及病案复印人次,并按用途对复印2259份精神疾病病案分类进行分析。结果精神疾病病案复印数量逐年增加,复印用途列第一位是办理慢性病补助占40.37%,其次为医保报销27%、办理低保11.78%、评残8.1%和公检法取证4.25%等。结论病案复印对患者个人和社会具有极高价值,精神专科医院应落实《医疗机构病案管理规定》,加强精神疾病病案复印管理,保证病案复印质量,使病案信息最大限度的为社会服务。
Objective To analyze the use of medical records for mental illness and improve the quality of medical records in mental hospitals. Methods The data of hospital 2007-2010 annual reports and mental illness were collected, and the number of hospital discharges and cases of medical records were counted. The classification of 2259 mental illness cases was analyzed according to the purpose. Results The number of copies of mental illness cases increased year by year. The first one was for copying, accounting for 40.37% of the total. The second was medical insurance reimbursement of 27%, the minimum guarantee of 11.78%, the 8.1% disability assessment and 4.25% of the total. Conclusion Medical records are of great value to individual patients and society. Psychiatric hospitals should implement the Medical Records Management Regulations, strengthen the management of mental illness copy, ensure the quality of medical records, and maximize the medical record information for the community.