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目的了解广西各级医院病案统计管理现状及存在的主要问题和原因,为DRGs在广西的推行和广西病案统计管理的改进提供有力依据。方法于2016年3月以分层抽样、简单随机抽样和邮寄调查问卷的方法在全区各级医院抽选110家医院,回收94份,回收率85.45%,用SPSS10.0统计软件整理与分析。结果有79.78%的医院病案统计科由分管院长直接领导或由医务处(科)管理;90.43%、76.60%和55.32%的病案统计科负责ICD编码、医院信息统计和病案书写质量控制工作;病案统计专业技术人员平均7人,52.04%有编码培训合格证,21.65%有统计证,4.15%有质控培训合格证;三级医院病案统计人员参加学习培训比例达68.72%的;87.23%的医院实现电子病历,23.40%的医院实现病案部分无纸化。结论广西各级医院应重视医院病案统计科的学科建设,加强病案统计从业人员的培训和继续教育,提高编码准确率和统计分析能力,增强病案统计科实力和提高病案统计管理水平,为医院发展提供精准数据,提升医院管理能力。
Objective To understand the status quo and existing main problems and causes of medical record management at all levels of hospitals in Guangxi and provide a strong evidence for the implementation of DRGs in Guangxi and the improvement of medical record management in Guangxi. Methods In March 2016, stratified sampling, simple random sampling and mail survey questionnaire method were used to select 110 hospitals in hospitals at all levels in the region, 94 of them were recovered, the recovery rate was 85.45%, and SPSS10.0 statistical software was used to collate and analyze . As a result, 79.78% of the cases were directly supervised by the director in charge of the hospital or managed by the medical department (department); 90.43%, 76.60% and 55.32% of the cases were in ICD coding, hospital information statistics and medical record quality control; The average number of professional and technical personnel in medical record statistics was 7, with 52.04% coding training certificate, 21.65% statistical certificate and 4.15% quality control training certificate. The proportion of medical record attendants in tertiary hospitals reached 68.72%, and 87.23% Hospital to achieve electronic medical records, 23.40% of the hospital part of the medical record paperless. Conclusions Guangxi hospitals at all levels should pay attention to the discipline construction of medical records and statistics department, strengthen the training and continuing education of medical record and statistics practitioners, improve the coding accuracy and statistical analysis ability, enhance the strength of medical records and statistics department and improve the statistical management of medical records, Provide accurate data to enhance hospital management capabilities.