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目的通过对近5年病案利用情况调查,探讨有利于提高病案管理质量和病案管理效率的方法。方法对我院2005年-2009年《出院病人登记表》、《外来病案借阅登记》、《内部病案借阅登记》及《成批病案借阅登记》的原始记录,进行分类统计。结果病案的利用率由2005年的31.81%提高到2009年的45.19%。2009年借阅病案统计的44.18%用于临床科研教学,占利用率的第一位。结论通过对病案利用者的培训、病案归档流程及分类的改造和出院病人的定题跟踪服务,让病案资源在医院的全面建设上发挥其重要的信息指导作用。
Objective To investigate the utilization of medical records in the past five years and explore ways to improve the quality of medical records management and the efficiency of medical records management. Methods The original records of Discharge Registration Form, Exceptional Medical Records Borrow Registration, Internal Medical Records Borrow Registration and Mass Medical Records Registration were collected from 2005 to 2009 in our hospital for classification statistics. Results The utilization rate of medical records increased from 31.81% in 2005 to 45.19% in 2009. 44.18% of the borrowed medical records in 2009 were used for clinical research and teaching, accounting for the highest utilization rate. Conclusion Through the training of medical record users, the process of medical record filing, the reorganization of classification and the fixed-point tracking service of discharged patients, the medical record resources play an important role in guiding the overall construction of the hospital.