Investigation on the Current Status of Medical Record Department Management in Yibin City
Objectives This study aims to investigate the current management status of medical record departments in 50 hospitals in Yibin City,with the aim of standardize the archive work of the medical records department and improve the professional quality of the medical records department managers.Methods On June 15,2023,a survey was conducted on various hospitals in Yibin City through the distribution of questionnaires.The data were organized and input into the Epidata3.1 system for descriptive analysis.Results Among the 50 surveyed medical institutions,24 used the International Classification of Diseases ICD-11 coding library and 20 used the national clinical version code library.64.29％of tertiary hospitals provided medical record mailing services and 52.78％of secondary hospitals provided medical record mailing services.All tertiary hospitals used electronic medical records,and 77.78％of secondary hospitals used electronic medical records.The medical record management staff in the surveyed hospitals were mainly college graduates or below,and 18 hospitals participated in further training.All hospitals surveyed managed inpatient medical records,and 9 of them managed inpatient,outpatient,and emergency medical records at the same time.Conclusions The main problems in medical record management in Yibin are the lack of medical record management personnel and technical personnel.The quality control of medical records is ineffective,and the quality inspection rate is too low.However,with the increasing emphasis on medical record management,the medical record management work of the medical record departments of 50 hospitals in Yibin City is gradually improving.
Case managementSituation surveyStaffing levelQuality control management
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