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目的探讨医院住院病案回收率的影响因素并提出整改措施。方法比较分析某两家三级甲等医院2016年1月1日-6月30日期间2日、3日、7日内病案回收率,并采用访谈和实际查看等方法收集两家医院在住院病案回收相关的规章制度和流程等。结果 A医院2日、3日、7日内病案回收率分别为44.27%、55.26%、85.22%,B医院的病案回收率分别为98.10%、99.72%、100.00%,两家医院在各时间段的病案回收率间的差异均有统计学意义(P<0.001)。结论通过病案回收率指标纳入临床科室绩效考核、优化病案回收流程和做好多部门协作与沟通等措施,提高病案回收率。
Objective To explore the influential factors of hospitalized medical records and propose corrective measures. Methods A comparative analysis was made on the rates of medical record recalls between January 1 and June 30, 2016 at the first and second class hospitals in the first two days, the third and the seventh days of 2016. The hospital records were collected by interview and actual examination Recycling related rules and procedures and processes. Results The recover rates of medical records in hospital A were 44.27%, 55.26% and 85.22% on the 2nd, 3rd and 7th days respectively. The recover rates of medical records in hospital B were 98.10%, 99.72% and 100.00% respectively. There was significant difference between the recovery rates (P <0.001). Conclusion Through the inclusion of indicators of the recovery rate of clinical performance evaluation of clinical departments, optimize the medical record recovery process and do a lot of departments to collaborate and communicate and other measures to improve the recovery rate of medical records.