Résumé
As medical record management is key to hospital management, a hospital introduced paperless practice of automatic archiving in the following practices. Clarification and identification of the scope of business system transformation, establishment of an architecture integrating various business systems, integration platform, hospital data center, archiving system and certification authority, creation of three automatic archiving processes: initial archiving, late return archiving and modification archiving, for refined management of the review and tracking of archived medical records. Thanks to this paperless management, the automatic archiving rate was as high as 95.95%for medical records, 96.47%for laboratory reports and 99.58%for medical orders respectively. A full-process and whole-cycle informationized closed loop management was achieved for the collection, archiving, review and utilization of medical records, substantially upgrading hospital informationization and medical record management.
Résumé
Objective To identify the problems of medical record management standardization in clinical case management for the study of medical record quality and give some corresponding measures.Methods 3,000 medical records of patients in our hospital from January 2015 to December 2016 were collected and divided into control group (with 1,500 records from January 2015 to December 2015) and observation group (with 1,500 clinical medical records from January 2016 to December 2016).The control group adopted regular data management while the observation group employed standardized lean management.Medical record defects, rectification rate and the average scores of inpatient medical records between the two groups were compared and analyzed.Results The average score of inpatient medical records in observation group was significantly higher than that of the control group (t=13.672, P<0.05), while the defect degree and the modification rate of the medical records were significantly lower than those of the control group (P<0.05).Conclusion Standardized medical record management contributes to the improvement of the quality of medical records.
Résumé
Modern medical record management is becoming more and more integrated with medical information management and computerization.With the changes in the content and mode of medical record management,the modernization of its means and the extension of its services,the managerial personnel must have such qualities as active service idea,multiple knowledge,a high sense of information,strengthened awareness of law,and abilities of communication and coordination,so as to meet the requirement of modern medical record management.
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Objective To find out about the current situation of the development of medical record management in Jiangxi Province. Methods Questionnaires were distributed to 182 medical record management workers in 98 hospitals of Jiangxi Province. Results Medical record management has witnessed slow development and the management contingent is characterized by low educational level, low professional titles, a rather limited number of years of work experience and numerical dominance of women. Conclusion That leaders in some hospitals fail to pay enough attention to medical record management and medical record management organizations have not been properly set up constitutes the chief cause of the slow development of the medical record management specialty in Jiangxi Province.