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病案是有关患者健康状况的文件资料,包括患者本人或他人对病情的主观描述和医务人员对患者的客观检查结果及医务人员对病情的分析、诊疗过程和转归情况的记录以及与之相关的具有法律意义的文书、单据。病案的回收管理是病案信息管理工作的第一步,只有对病案做到及时回收,才能确保其发挥应有的功能。在实际工作中,普遍存在病案延迟归档的现象,不仅影响数据统计及利用、质量监控,甚至造成患方不必要投诉和纠纷。本文主要分析病案延迟归档所造成的影响以及消除这些影响的对策。
Medical records are documents relating to the patient’s health status, including the subjective description of the patient’s own or other person’s condition, the objective examination of the patient by the medical staff and the medical staff’s analysis of the condition, the course of the medical treatment and the outcome of the case, and the related Legal instruments, documents. The recovery management of medical records is the first step in the management of medical records information. Only when medical records are recovered in time can we ensure that it functions properly. In actual work, there is a widespread phenomenon of delayed filing of medical records, which not only affects data statistics and utilization, quality control, and even causes unnecessary complaints and disputes among patients. This article analyzes the impact of filing delayed filing and countermeasures to eliminate these effects.