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目的探讨出院病历及时归档的管理方法。方法通过对病案及时归档重要性的分析,发现病历迟归的原因。在实际工作中,建章立制,设计一套科学的病历归档管理软件,公平、透明的产出“病历归档及时率月报表”对临床科室进行公平的归档质量评价,将“病历七日归档率”指标纳入医院“医疗质量与安全考核指标”系统中进行常态化监督管理。结果通过两年的实践管理和不断改进,出院病历的归档及时率大大提高,并能最终保持在目标范围内。结论病案管理人员要加强认识,勇于担当,要有管理意识。病历归档及时性管理要有完整的、可实际操作执行的制度、措施和评价分析系统。在工作中要注重和临床医师及相关部门的沟通,做到公正公平,持续改进,在保证病历质量的前提下,努力提高病案归档及时率。
Objective To investigate the management of discharged records in time. Methods By analyzing the importance of timely filing of medical records, we find out the reasons for the medical records to be late. In practice, the establishment of a system of rules and regulations, the design of a scientific medical records management software, fair and transparent output “medical records filed in a timely manner on the monthly report ” of the clinical departments of the fair archive quality evaluation, “medical records Seven days archiving rate ”indicators into the hospital “ medical quality and safety assessment indicators ”system for the normalization of supervision and management. Results After two years of practical management and continuous improvement, the timely filing of discharged medical records was greatly enhanced and could eventually remain within the target scope. Conclusion The medical record management personnel should strengthen their cognition, be brave in taking responsibility, and have management sense. Timely archiving records management should have a complete, practical implementation of the system, measures and evaluation system. At work, we should pay attention to communication with clinicians and relevant departments to achieve fairness and continuous improvement, and strive to improve the rate of filing of medical records on the premise of ensuring the quality of medical records.