CAJ | 학술논문

目的：通过分析某院住院病案复印数量、用途及科别构成，为完善医院的病案管理工作、提高医院质量管理水平提供依据。方法对某院2013年～2014年病案复印申请单进行回顾性研究和分析，采用Excel表格进行数据统计和分析。结果某院共出院患者85144人次，复印病案6365例，复印的比率占7.5%。复印用途方面61.4%是为报销凭证，其次分别是办理社保慢性病卡、医学伤残等级鉴定、继续治疗资料留档、商业保险等。复印科别以普通外科（包括腹部外科、肝胆外科）、骨科、颅脑外科、妇产科为主。结论病案复印，使病案成为医院的一把双刃剑，医院必须提高质量管理水平，强化医务人员的法律意识和服务意识，严格执行《医疗机构病历管理规定》。
목적：통과분석모원주원병안복인수량、용도급과별구성，위완선의원적병안관리공작、제고의원질량관리수평제공의거。방법대모원2013년～2014년병안복인신청단진행회고성연구화분석，채용Excel표격진행수거통계화분석。결과모원공출원환자85144인차，복인병안6365례，복인적비솔점7.5%。복인용도방면61.4%시위보소빙증，기차분별시판리사보만성병잡、의학상잔등급감정、계속치료자료류당、상업보험등。복인과별이보통외과（포괄복부외과、간담외과）、골과、로뇌외과、부산과위주。결론병안복인，사병안성위의원적일파쌍인검，의원필수제고질량관리수평，강화의무인원적법률의식화복무의식，엄격집행《의료궤구병력관리규정》。
Objective To analyze the number of a hospital inpatient medical record’s copies, uses and divisions constitute. To provide reference for improving the management of the hospital's medical record, and promote hospital quality management.Methods Medical record copying requisitions from 2013 to 2014 were retrospectively studied and analyzed using an Excel spreadsheet.Results There are 85,144 discharged patients, and 6,365 copying medical records, the copying ratio is 7.5%. 61.4% for the reimbursement voucher, followed by the chronic diseases for social security card, medical disability grade identification, continue treatment data on file, commercial insurance. The General divisions are general surgery(including abdominal surgery, hepatobiliary surgery), brain surgery, orthopedic surgery, obstetrics and gynecology.Conclusion Medical records duplication makes hospital medical record as a double-edged sword. Hospital must improve the quality management level, strengthen legal consciousness and service consciousness of medical staff, strictly implement the regulations on the medical record management of medical institutions.