Investigation and Analysis on the Current Status of Medical Record Management in 129 Medical Institutions in Deyang City
Objectives This study aims to Understand the current status of medical record management departments in various medical institutions in Deyang City and provide an objective basis for promoting the scientific construction of medical record management departments in the city.Methods From April 26 to May 21,2023,a questionnaire survey was used to collect the basic information,personnel allocation,business development,information construction and other contents of the medical records department of 129 medical institutions.Each medical institution filled in the professional baseline survey form for medical record management with real name.Results Among the 129 medical institutions,72 medical record departments were subordinate to the medical department,accounting for 55.81％.Medical records staff aged 30-39 accounted for38.18％,undergraduate staff accounted for 54.13％,and medical related professionals accounted for 51.00％.The ratio of actual number of open beds to medical record personnel was 86.9∶1.89.15％of hospitals carried out quality control on the front page of inpatient medical records.The accuracy rate of main diagnosis coding was greater than 90％in 79.84％of hospitals.5.43％of the respondents provided online medical record copying reservation services.Only 7.75％of hospitals used digital scanning.Conclusions The medical record management departments of some medical institutions in Deyang City are not set up properly.There are not enough medical record management personnel,and the education and professional configuration of full-time staff is not reasonable.These hospitals need to further improve department affiliation,strengthen personnel team building,optimize department personnel structure,improve business capabilities,and at the same time strengthen information construction to provide support for modern medical record management.
Medical record managementCurrent situation investigationAnalysis
NETL
NSTL
万方数据
