摘要：目(mu)的探討(tao)精細(xi)化(hua)管(guan)(guan)理(li)在病(bing)(bing)案(an)室(shi)病(bing)(bing)案(an)管(guan)(guan)理(li)中的應用效(xiao)果。方法(fa)(fa)(fa)選擇本(ben)院自(zi)2013年2月(yue)至(zhi)2018年2月(yue)的病(bing)(bing)案(an)400份，對(dui)(dui)(dui)(dui)全(quan)部病(bing)(bing)例(li)(li)(li)資(zi)料(liao)進(jin)行(xing)分析并(bing)分組(zu)(zu)(zu)(zu)，對(dui)(dui)(dui)(dui)照組(zu)(zu)(zu)(zu)運用傳統(tong)病(bing)(bing)例(li)(li)(li)管(guan)(guan)理(li)方法(fa)(fa)(fa)對(dui)(dui)(dui)(dui)病(bing)(bing)例(li)(li)(li)進(jin)行(xing)管(guan)(guan)理(li)，觀察組(zu)(zu)(zu)(zu)運用精細(xi)化(hua)管(guan)(guan)理(li)方法(fa)(fa)(fa)對(dui)(dui)(dui)(dui)病(bing)(bing)例(li)(li)(li)進(jin)行(xing)管(guan)(guan)理(li)，觀察并(bing)對(dui)(dui)(dui)(dui)比兩(liang)(liang)種(zhong)方法(fa)(fa)(fa)具(ju)(ju)體的實施效(xiao)果。結果通(tong)過(guo)對(dui)(dui)(dui)(dui)兩(liang)(liang)組(zu)(zu)(zu)(zu)施以不(bu)同的病(bing)(bing)案(an)管(guan)(guan)理(li)方法(fa)(fa)(fa)可知，觀察組(zu)(zu)(zu)(zu)醫(yi)患矛盾(dun)發(fa)生率(lv)明顯低(di)(di)(di)于(yu)(yu)(yu)對(dui)(dui)(dui)(dui)照組(zu)(zu)(zu)(zu)，且病(bing)(bing)案(an)資(zi)料(liao)的破損率(lv)與缺失率(lv)低(di)(di)(di)于(yu)(yu)(yu)對(dui)(dui)(dui)(dui)照組(zu)(zu)(zu)(zu)，數據對(dui)(dui)(dui)(dui)比差異具(ju)(ju)有(you)統(tong)計學(xue)意義（P＜0.05）。此外，觀察組(zu)(zu)(zu)(zu)管(guan)(guan)理(li)人員綜合素(su)質評分明顯優于(yu)(yu)(yu)對(dui)(dui)(dui)(dui)照組(zu)(zu)(zu)(zu)，差異具(ju)(ju)有(you)統(tong)計學(xue)意義（P＜0.05）。結論(lun)將精細(xi)化(hua)管(guan)(guan)理(li)模式運用于(yu)(yu)(yu)病(bing)(bing)案(an)室(shi)病(bing)(bing)案(an)管(guan)(guan)理(li)中能夠降低(di)(di)(di)或避(bi)免(mian)醫(yi)患矛盾(dun)的發(fa)生率(lv)，提(ti)高管(guan)(guan)理(li)人員的綜合素(su)質，具(ju)(ju)有(you)較好(hao)的應用價(jia)值，值得研(yan)究推廣。

關鍵詞：精細(xi)化管理(li)；病案室；病案管理(li)；效果(guo)

病(bing)案(an)室(shi)主要負責(ze)醫(yi)院患(huan)者(zhe)病(bing)案(an)的(de)(de)(de)保(bao)管(guan)，其病(bing)案(an)需(xu)將患(huan)者(zhe)個(ge)人信息、具體病(bing)情(qing)(qing)、醫(yi)護人員對其進(jin)(jin)行(xing)(xing)(xing)的(de)(de)(de)治療(liao)措施(shi)與行(xing)(xing)(xing)為，以(yi)及患(huan)者(zhe)所進(jin)(jin)行(xing)(xing)(xing)的(de)(de)(de)檢查及結果、使用藥品等(deng)情(qing)(qing)況(kuang)(kuang)詳細地記(ji)錄在(zai)案(an)[1]。近年來，隨著(zhu)醫(yi)療(liao)技術(shu)的(de)(de)(de)發展(zhan)與醫(yi)改方案(an)的(de)(de)(de)進(jin)(jin)步(bu)以(yi)及患(huan)者(zhe)自我(wo)保(bao)護意(yi)識的(de)(de)(de)增(zeng)強，建立健全的(de)(de)(de)病(bing)案(an)室(shi)病(bing)案(an)管(guan)理辦法是各醫(yi)院亟需(xu)解決的(de)(de)(de)問題[2]。本研究(jiu)通過(guo)對比本院病(bing)案(an)室(shi)在(zai)實施(shi)精細化(hua)管(guan)理前后的(de)(de)(de)具體情(qing)(qing)況(kuang)(kuang)進(jin)(jin)行(xing)(xing)(xing)探(tan)討(tao)，分析精細化(hua)管(guan)理的(de)(de)(de)應(ying)用價值，現報道如下。

1資料與方法

1.1臨床資料(liao)(liao)(liao)。選擇(ze)本(ben)院(yuan)自(zi)2013年(nian)(nian)2月至(zhi)2018年(nian)(nian)2月的(de)(de)(de)(de)(de)(de)(de)(de)(de)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)400份，對(dui)(dui)其(qi)(qi)進(jin)(jin)(jin)行回顧性分(fen)(fen)析；其(qi)(qi)中2013年(nian)(nian)2月至(zhi)2015年(nian)(nian)2月期(qi)(qi)間(jian)均(jun)使用(yong)(yong)傳(chuan)統(tong)(tong)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)例(li)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)方(fang)法(fa)，2015年(nian)(nian)3月至(zhi)2018年(nian)(nian)2月期(qi)(qi)間(jian)已(yi)開始對(dui)(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)室病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)例(li)實(shi)施(shi)精細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)方(fang)法(fa)；根(gen)(gen)據(ju)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)方(fang)法(fa)的(de)(de)(de)(de)(de)(de)(de)(de)(de)不(bu)(bu)(bu)(bu)同(tong)將(jiang)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)例(li)分(fen)(fen)為(wei)對(dui)(dui)照(zhao)組(zu)(zu)(zu)與觀察(cha)組(zu)(zu)(zu)，每(mei)組(zu)(zu)(zu)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)例(li)200份。所(suo)選資料(liao)(liao)(liao)均(jun)由本(ben)院(yuan)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)室病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)例(li)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)人員(yuan)進(jin)(jin)(jin)行記錄(lu)與統(tong)(tong)計(ji)(ji)，其(qi)(qi)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)例(li)資料(liao)(liao)(liao)比(bi)較差異(yi)(yi)無統(tong)(tong)計(ji)(ji)學意義(yi)，具有(you)可比(bi)性。1.2方(fang)法(fa)。對(dui)(dui)照(zhao)組(zu)(zu)(zu)予以(yi)傳(chuan)統(tong)(tong)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)例(li)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)方(fang)法(fa)。觀察(cha)組(zu)(zu)(zu)予以(yi)精細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)方(fang)法(fa)，具體(ti)內(nei)容(rong)如(ru)下(xia)：①重(zhong)視(shi)精細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)意義(yi)。對(dui)(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)室病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)人員(yuan)及(ji)相(xiang)關(guan)的(de)(de)(de)(de)(de)(de)(de)(de)(de)醫護人員(yuan)進(jin)(jin)(jin)行病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)精細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)培訓，宣講精細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)的(de)(de)(de)(de)(de)(de)(de)(de)(de)內(nei)容(rong)與價值，重(zhong)視(shi)精細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)的(de)(de)(de)(de)(de)(de)(de)(de)(de)實(shi)施(shi)，不(bu)(bu)(bu)(bu)斷完善病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)的(de)(de)(de)(de)(de)(de)(de)(de)(de)信息記錄(lu)方(fang)式(shi)(shi)，且(qie)在(zai)培訓后適時(shi)進(jin)(jin)(jin)行考(kao)核(he)，保(bao)證(zheng)(zheng)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)精細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)的(de)(de)(de)(de)(de)(de)(de)(de)(de)有(you)效(xiao)運營。②權責分(fen)(fen)明，規(gui)范制(zhi)度(du)(du)。病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)的(de)(de)(de)(de)(de)(de)(de)(de)(de)建立過(guo)程(cheng)較長，需(xu)將(jiang)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)內(nei)容(rong)進(jin)(jin)(jin)行細(xi)(xi)(xi)分(fen)(fen)并(bing)根(gen)(gen)據(ju)其(qi)(qi)內(nei)容(rong)的(de)(de)(de)(de)(de)(de)(de)(de)(de)差異(yi)(yi)化(hua)(hua)(hua)(hua)建立相(xiang)應(ying)的(de)(de)(de)(de)(de)(de)(de)(de)(de)執行標準(zhun)；同(tong)時(shi)安排相(xiang)關(guan)負責人員(yuan)按照(zhao)流程(cheng)與標準(zhun)將(jiang)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)患(huan)的(de)(de)(de)(de)(de)(de)(de)(de)(de)情(qing)況(kuang)(kuang)記錄(lu)在(zai)案(an)(an)(an)(an)(an)，保(bao)證(zheng)(zheng)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)錄(lu)入(ru)的(de)(de)(de)(de)(de)(de)(de)(de)(de)規(gui)范化(hua)(hua)(hua)(hua)，便(bian)于(yu)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)室的(de)(de)(de)(de)(de)(de)(de)(de)(de)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)；如(ru)將(jiang)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)資料(liao)(liao)(liao)所(suo)涉及(ji)的(de)(de)(de)(de)(de)(de)(de)(de)(de)內(nei)容(rong)進(jin)(jin)(jin)行錄(lu)入(ru)、回收、整理(li)(li)(li)(li)(li)、編(bian)檔(dang)與歸檔(dang)，并(bing)及(ji)時(shi)將(jiang)該(gai)資料(liao)(liao)(liao)信息錄(lu)入(ru)電(dian)腦(nao)，制(zhi)作電(dian)子信息病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)[3]。此外，對(dui)(dui)于(yu)患(huan)者(zhe)(zhe)需(xu)要備份病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)的(de)(de)(de)(de)(de)(de)(de)(de)(de)情(qing)況(kuang)(kuang)要核(he)實(shi)患(huan)者(zhe)(zhe)的(de)(de)(de)(de)(de)(de)(de)(de)(de)實(shi)際身份，并(bing)在(zai)患(huan)者(zhe)(zhe)備份后將(jiang)該(gai)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)及(ji)時(shi)歸檔(dang)存放[4]。③建立完善的(de)(de)(de)(de)(de)(de)(de)(de)(de)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)考(kao)核(he)制(zhi)度(du)(du)。根(gen)(gen)據(ju)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)記錄(lu)、保(bao)存、整理(li)(li)(li)(li)(li)等(deng)方(fang)式(shi)(shi)的(de)(de)(de)(de)(de)(de)(de)(de)(de)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)標準(zhun)，制(zhi)定相(xiang)應(ying)的(de)(de)(de)(de)(de)(de)(de)(de)(de)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)考(kao)核(he)制(zhi)度(du)(du)，安排考(kao)核(he)監(jian)督員(yuan)對(dui)(dui)相(xiang)關(guan)人員(yuan)進(jin)(jin)(jin)行不(bu)(bu)(bu)(bu)定期(qi)(qi)的(de)(de)(de)(de)(de)(de)(de)(de)(de)巡查，如(ru)發(fa)現(xian)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)人員(yuan)在(zai)記錄(lu)患(huan)者(zhe)(zhe)信息時(shi)書寫(xie)不(bu)(bu)(bu)(bu)規(gui)范，內(nei)容(rong)有(you)瑕疵，或在(zai)其(qi)(qi)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)時(shi)出現(xian)失當行為(wei)，監(jian)督員(yuan)可及(ji)時(shi)指正，并(bing)將(jiang)該(gai)行為(wei)記錄(lu)在(zai)冊作為(wei)考(kao)核(he)的(de)(de)(de)(de)(de)(de)(de)(de)(de)依據(ju)[5]。制(zhi)定相(xiang)應(ying)的(de)(de)(de)(de)(de)(de)(de)(de)(de)獎懲制(zhi)度(du)(du)并(bing)嚴格(ge)落實(shi)，不(bu)(bu)(bu)(bu)斷提升病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)人員(yuan)的(de)(de)(de)(de)(de)(de)(de)(de)(de)工作效(xiao)率，為(wei)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)精細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)提供基礎保(bao)證(zheng)(zheng)。④完善病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)精細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)的(de)(de)(de)(de)(de)(de)(de)(de)(de)工作制(zhi)度(du)(du)。定期(qi)(qi)召開病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)會議，總結在(zai)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)中發(fa)生的(de)(de)(de)(de)(de)(de)(de)(de)(de)問(wen)題并(bing)提供相(xiang)應(ying)的(de)(de)(de)(de)(de)(de)(de)(de)(de)解(jie)決方(fang)案(an)(an)(an)(an)(an)；不(bu)(bu)(bu)(bu)斷完善病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)制(zhi)度(du)(du)及(ji)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)工作制(zhi)度(du)(du)，提高病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)精細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)模式(shi)(shi)的(de)(de)(de)(de)(de)(de)(de)(de)(de)運用(yong)(yong)效(xiao)果(guo)。1.3觀察(cha)標準(zhun)。觀察(cha)兩組(zu)(zu)(zu)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)首頁記錄(lu)質(zhi)量，首頁質(zhi)量評判內(nei)容(rong)包括患(huan)者(zhe)(zhe)姓名、年(nian)(nian)齡、身份證(zheng)(zheng)號、住址、聯(lian)系方(fang)式(shi)(shi)以(yi)及(ji)單位(wei)等(deng)基本(ben)信息的(de)(de)(de)(de)(de)(de)(de)(de)(de)填寫(xie)情(qing)況(kuang)(kuang)，無缺項(xiang)(xiang)漏填等(deng)情(qing)況(kuang)(kuang)即視(shi)為(wei)合格(ge)，反之為(wei)不(bu)(bu)(bu)(bu)合格(ge)。調(diao)查并(bing)對(dui)(dui)比(bi)兩組(zu)(zu)(zu)醫患(huan)糾紛(fen)的(de)(de)(de)(de)(de)(de)(de)(de)(de)發(fa)生率、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)缺項(xiang)(xiang)漏項(xiang)(xiang)的(de)(de)(de)(de)(de)(de)(de)(de)(de)情(qing)況(kuang)(kuang)以(yi)及(ji)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)人員(yuan)其(qi)(qi)職位(wei)職能(neng)的(de)(de)(de)(de)(de)(de)(de)(de)(de)考(kao)核(he)情(qing)況(kuang)(kuang)。病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)人員(yuan)的(de)(de)(de)(de)(de)(de)(de)(de)(de)考(kao)核(he)標準(zhun)內(nei)容(rong)包括理(li)(li)(li)(li)(li)論、技術(shu)以(yi)及(ji)日常績效(xiao)的(de)(de)(de)(de)(de)(de)(de)(de)(de)考(kao)核(he)，其(qi)(qi)考(kao)核(he)內(nei)容(rong)每(mei)項(xiang)(xiang)滿分(fen)(fen)為(wei)100分(fen)(fen)，＞60分(fen)(fen)即為(wei)合格(ge)。1.4統(tong)(tong)計(ji)(ji)學方(fang)法(fa)。本(ben)研究數據(ju)均(jun)用(yong)(yong)SPSS17.0統(tong)(tong)計(ji)(ji)軟(ruan)件處(chu)理(li)(li)(li)(li)(li)，計(ji)(ji)量資料(liao)(liao)(liao)采(cai)用(yong)(yong)“x±s”表示，組(zu)(zu)(zu)間(jian)比(bi)較采(cai)用(yong)(yong)t檢驗，計(ji)(ji)數資料(liao)(liao)(liao)用(yong)(yong)例(li)數（n）表示，計(ji)(ji)數資料(liao)(liao)(liao)組(zu)(zu)(zu)間(jian)率（%）的(de)(de)(de)(de)(de)(de)(de)(de)(de)比(bi)較采(cai)用(yong)(yong)c2檢驗，P＜0.05為(wei)差異(yi)(yi)有(you)統(tong)(tong)計(ji)(ji)學意義(yi)。

2結果

1加強病案(an)信(xin)息(xi)質(zhi)量管理

病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)是醫院(yuan)各(ge)項(xiang)工(gong)作開展(zhan)的(de)(de)(de)(de)(de)(de)基礎和(he)(he)出發(fa)點，病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)數(shu)(shu)據(ju)的(de)(de)(de)(de)(de)(de)真(zhen)實(shi)性(xing)(xing)(xing)、完(wan)整性(xing)(xing)(xing)和(he)(he)準(zhun)(zhun)確(que)性(xing)(xing)(xing)直(zhi)接(jie)影(ying)(ying)響了病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)的(de)(de)(de)(de)(de)(de)科(ke)學(xue)利(li)用(yong)。為能使病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)得到合理(li)(li)、科(ke)學(xue)開發(fa)和(he)(he)利(li)用(yong)，就必須保證病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)的(de)(de)(de)(de)(de)(de)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)。相關研究認為，病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)的(de)(de)(de)(de)(de)(de)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)是做好病(bing)(bing)(bing)(bing)(bing)案(an)(an)開發(fa)與利(li)用(yong)的(de)(de)(de)(de)(de)(de)基礎。病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)是醫院(yuan)管(guan)(guan)(guan)理(li)(li)工(gong)作的(de)(de)(de)(de)(de)(de)原始信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)源，信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)的(de)(de)(de)(de)(de)(de)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)影(ying)(ying)響著(zhu)(zhu)科(ke)室(shi)工(gong)作指(zhi)標的(de)(de)(de)(de)(de)(de)統計及各(ge)項(xiang)醫療統計報(bao)告(gao)數(shu)(shu)據(ju)的(de)(de)(de)(de)(de)(de)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)，同時(shi)也影(ying)(ying)響著(zhu)(zhu)醫療科(ke)研的(de)(de)(de)(de)(de)(de)成果和(he)(he)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)，關系(xi)著(zhu)(zhu)整個(ge)醫院(yuan)的(de)(de)(de)(de)(de)(de)運營與發(fa)展(zhan)。為此，醫院(yuan)必須加強(qiang)病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)的(de)(de)(de)(de)(de)(de)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)管(guan)(guan)(guan)理(li)(li)。首先，制(zhi)定一系(xi)列管(guan)(guan)(guan)理(li)(li)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)，包括病(bing)(bing)(bing)(bing)(bing)歷書寫規范、病(bing)(bing)(bing)(bing)(bing)歷質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)標準(zhun)(zhun)、病(bing)(bing)(bing)(bing)(bing)歷質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)管(guan)(guan)(guan)理(li)(li)制(zhi)度(du)、病(bing)(bing)(bing)(bing)(bing)案(an)(an)室(shi)工(gong)作制(zhi)度(du)等[1]；其次，不斷完(wan)善(shan)病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)的(de)(de)(de)(de)(de)(de)三級管(guan)(guan)(guan)控體系(xi)，同時(shi)加大質(zhi)(zhi)(zhi)(zhi)(zhi)管(guan)(guan)(guan)部門的(de)(de)(de)(de)(de)(de)執法力度(du)，嚴格(ge)依病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)管(guan)(guan)(guan)理(li)(li)制(zhi)度(du)行事(shi)，做到獎懲(cheng)分(fen)(fen)明；再次，定期開展(zhan)病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)問(wen)題分(fen)(fen)析活動，及時(shi)反映病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)所存在(zai)的(de)(de)(de)(de)(de)(de)問(wen)題，并(bing)采取相應措施加以(yi)解(jie)決(jue)，以(yi)切(qie)實(shi)提高(gao)病(bing)(bing)(bing)(bing)(bing)案(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)質(zhi)(zhi)(zhi)(zhi)(zhi)量(liang)(liang)。

2充(chong)分利(li)用(yong)現代化管理工具

伴隨科學(xue)技(ji)(ji)術的(de)(de)(de)發(fa)展(zhan)，諸多(duo)新型科學(xue)技(ji)(ji)術不(bu)斷引入醫院工作當中，其中也包括病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)的(de)(de)(de)管理(li)。利(li)用高(gao)(gao)(gao)新技(ji)(ji)術既可(ke)深入開發(fa)病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)，以提(ti)(ti)高(gao)(gao)(gao)病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)的(de)(de)(de)利(li)用率，又能實(shi)現(xian)(xian)病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)的(de)(de)(de)資(zi)源(yuan)共享，擴大病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)的(de)(de)(de)使用范圍(wei)。通過建立病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)網絡，還(huan)可(ke)實(shi)現(xian)(xian)病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)管理(li)的(de)(de)(de)電子化，實(shi)現(xian)(xian)病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)接收、傳遞、存儲和(he)利(li)用的(de)(de)(de)一體化。近些年(nian)來(lai)，很多(duo)大中型醫院紛紛引入高(gao)(gao)(gao)新科技(ji)(ji)產品以實(shi)現(xian)(xian)病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)的(de)(de)(de)存儲、加(jia)工和(he)管理(li)。如利(li)用計算機磁盤(pan)或光(guang)盤(pan)等可(ke)實(shi)現(xian)(xian)病(bing)(bing)(bing)(bing)案(an)(an)(an)的(de)(de)(de)數字化存儲，替(ti)代了(le)原有紙質病(bing)(bing)(bing)(bing)案(an)(an)(an)的(de)(de)(de)保存，節約了(le)很多(duo)物理(li)空間。如利(li)用光(guang)盤(pan)掃描儀、掃描閱讀器、微縮(suo)拍(pai)照(zhao)機、激光(guang)打印機等可(ke)對現(xian)(xian)有病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)進行復(fu)制并輸(shu)出，有效(xiao)提(ti)(ti)高(gao)(gao)(gao)了(le)病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)的(de)(de)(de)傳輸(shu)速度，同時也方便(bian)使用者隨時、快速提(ti)(ti)取(qu)所(suo)需病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)[2]。此外(wai)，利(li)用電子病(bing)(bing)(bing)(bing)案(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)還(huan)可(ke)實(shi)現(xian)(xian)專家遠程(cheng)(cheng)會診、遠程(cheng)(cheng)技(ji)(ji)術指導等，實(shi)現(xian)(xian)了(le)醫療信(xin)(xin)(xin)(xin)息(xi)(xi)(xi)(xi)(xi)的(de)(de)(de)共享，有利(li)于醫療事業的(de)(de)(de)發(fa)展(zhan)。

3轉變服務模式

在(zai)新(xin)(xin)形勢下(xia)，病(bing)案(an)(an)(an)信(xin)(xin)息(xi)(xi)管理也(ye)發生了(le)很多(duo)變(bian)化，包括(kuo)：管理模式、管理方式、管理內(nei)涵(han)、服(fu)務范(fan)圍等。為(wei)(wei)能在(zai)新(xin)(xin)形勢下(xia)獲(huo)得長足(zu)發展，就要(yao)求(qiu)病(bing)案(an)(an)(an)信(xin)(xin)息(xi)(xi)管理轉(zhuan)變(bian)傳統(tong)觀(guan)念，認識到(dao)管理的(de)(de)目的(de)(de)在(zai)于(yu)利(li)用，病(bing)案(an)(an)(an)信(xin)(xin)息(xi)(xi)管理應由傳統(tong)的(de)(de)勞動(dong)服(fu)務型(xing)逐步轉(zhuan)向智能服(fu)務型(xing)，將被動(dong)服(fu)務變(bian)為(wei)(wei)主動(dong)，由零(ling)散(san)式的(de)(de)服(fu)務漸漸轉(zhuan)化成(cheng)系統(tong)式的(de)(de)服(fu)務。對(dui)病(bing)案(an)(an)(an)信(xin)(xin)息(xi)(xi)管理實施創(chuang)造性(xing)開(kai)展，通(tong)過分析、研究病(bing)案(an)(an)(an)信(xin)(xin)息(xi)(xi)內(nei)容，并依(yi)專題需(xu)求(qiu)進(jin)行加工(gong)，從而(er)形成(cheng)新(xin)(xin)的(de)(de)知識產品。這種經摘編后的(de)(de)知識產品濃(nong)縮的(de)(de)整個病(bing)案(an)(an)(an)信(xin)(xin)息(xi)(xi)的(de)(de)精華內(nei)容，可(ke)有效指(zhi)導醫院(yuan)工(gong)作的(de)(de)開(kai)展，同(tong)時也(ye)是對(dui)現(xian)有病(bing)案(an)(an)(an)信(xin)(xin)息(xi)(xi)的(de)(de)二(er)次(ci)創(chuang)作。病(bing)案(an)(an)(an)信(xin)(xin)息(xi)(xi)的(de)(de)服(fu)務與(yu)利(li)用充分體現(xian)了(le)“以人(ren)為(wei)(wei)本”的(de)(de)醫院(yuan)服(fu)務理念，使利(li)用者深(shen)入了(le)解了(le)用戶的(de)(de)基本信(xin)(xin)息(xi)(xi)，通(tong)過獲(huo)取病(bing)案(an)(an)(an)信(xin)(xin)息(xi)(xi)，了(le)解了(le)患者需(xu)求(qiu)與(yu)期望，進(jin)而(er)依(yi)患者實際情況進(jin)行研究與(yu)治療，真正實現(xian)全(quan)方位服(fu)務，從而(er)提高服(fu)務滿(man)意度(du)，擴大醫院(yuan)影響力。

1資料與方法

1.1一般資料

特(te)選擇該院內(nei)科作為(wei)(wei)(wei)(wei)調查(cha)研究的科室。該科室護(hu)士27名，年(nian)(nian)齡在23~42歲(sui)，平(ping)(ping)均(jun)(jun)年(nian)(nian)齡為(wei)(wei)(wei)(wei)（32.13±2.45）歲(sui)；醫生(sheng)6名，男(nan)性(xing)(xing)(xing)5名，女(nv)(nv)性(xing)(xing)(xing)1名；年(nian)(nian)齡在33~48歲(sui)，平(ping)(ping)均(jun)(jun)年(nian)(nian)齡為(wei)(wei)(wei)(wei)（40.23±4.53）歲(sui)；另選取(qu)2013年(nian)(nian)9月(yue)(yue)—2014年(nian)(nian)8月(yue)(yue)在該院內(nei)科接(jie)受(shou)治療的患(huan)者(zhe)(zhe)41例(li)(li)(li)，將(jiang)其設(she)為(wei)(wei)(wei)(wei)試(shi)驗(yan)組(zu)，試(shi)驗(yan)組(zu)中，男(nan)性(xing)(xing)(xing)患(huan)者(zhe)(zhe)32例(li)(li)(li)，女(nv)(nv)性(xing)(xing)(xing)患(huan)者(zhe)(zhe)9例(li)(li)(li)；患(huan)者(zhe)(zhe)年(nian)(nian)齡在6~67歲(sui)，平(ping)(ping)均(jun)(jun)年(nian)(nian)齡為(wei)(wei)(wei)(wei)（38.13±2.01）歲(sui)；病(bing)程(cheng)為(wei)(wei)(wei)(wei)2個月(yue)(yue)~2年(nian)(nian)，平(ping)(ping)均(jun)(jun)病(bing)程(cheng)為(wei)(wei)(wei)(wei)（0.88±2.51）年(nian)(nian)。同時，選取(qu)2012年(nian)(nian)9月(yue)(yue)—2013年(nian)(nian)8月(yue)(yue)期間收治的41例(li)(li)(li)患(huan)者(zhe)(zhe)，將(jiang)其設(she)為(wei)(wei)(wei)(wei)對(dui)照組(zu)，對(dui)照組(zu)中，男(nan)性(xing)(xing)(xing)患(huan)者(zhe)(zhe)38例(li)(li)(li)，女(nv)(nv)性(xing)(xing)(xing)患(huan)者(zhe)(zhe)3例(li)(li)(li)；患(huan)者(zhe)(zhe)年(nian)(nian)齡在8~59歲(sui)，平(ping)(ping)均(jun)(jun)年(nian)(nian)齡為(wei)(wei)(wei)(wei)（33±3.51）歲(sui)；病(bing)程(cheng)為(wei)(wei)(wei)(wei)1個月(yue)(yue)~4年(nian)(nian)，平(ping)(ping)均(jun)(jun)病(bing)程(cheng)為(wei)(wei)(wei)(wei)（2.21±3.50）年(nian)(nian)。兩組(zu)患(huan)者(zhe)(zhe)在性(xing)(xing)(xing)別(bie)、年(nian)(nian)齡、病(bing)程(cheng)等基本資(zi)料方面均(jun)(jun)具有可比性(xing)(xing)(xing)，差異無統計學意義。

1.2方法

首先，對(dui)(dui)(dui)該科室(shi)選擇出(chu)來的(de)(de)(de)(de)(de)41例對(dui)(dui)(dui)照(zhao)組(zu)患者的(de)(de)(de)(de)(de)醫(yi)(yi)院病(bing)案(an)(an)(an)進行(xing)(xing)(xing)(xing)研(yan)究與(yu)分(fen)(fen)析(xi)，并(bing)對(dui)(dui)(dui)管理(li)病(bing)案(an)(an)(an)的(de)(de)(de)(de)(de)人(ren)員進行(xing)(xing)(xing)(xing)整(zheng)體評(ping)估。隨后(hou)，在(zai)2013年9月—2014年8月期(qi)間(jian)，對(dui)(dui)(dui)該科室(shi)實施績效(xiao)考核，并(bing)對(dui)(dui)(dui)試驗組(zu)患者的(de)(de)(de)(de)(de)醫(yi)(yi)院病(bing)案(an)(an)(an)進行(xing)(xing)(xing)(xing)分(fen)(fen)析(xi)與(yu)探(tan)討(tao)。應(ying)(ying)根據(ju)每個醫(yi)(yi)務(wu)(wu)人(ren)員的(de)(de)(de)(de)(de)崗位、風(feng)險系數、工作性質開(kai)始(shi)制(zhi)定(ding)績效(xiao)考核的(de)(de)(de)(de)(de)標準(zhun)，應(ying)(ying)反復(fu)(fu)探(tan)討(tao)修改(gai)，以(yi)確(que)保績效(xiao)考核可(ke)以(yi)順利開(kai)展。績效(xiao)考核的(de)(de)(de)(de)(de)分(fen)(fen)配應(ying)(ying)統(tong)一采用(yong)考核計分(fen)(fen)的(de)(de)(de)(de)(de)方法，根據(ju)工作數量、工作人(ren)員的(de)(de)(de)(de)(de)完成(cheng)情況進行(xing)(xing)(xing)(xing)計分(fen)(fen)。管理(li)病(bing)案(an)(an)(an)的(de)(de)(de)(de)(de)人(ren)員應(ying)(ying)充分(fen)(fen)分(fen)(fen)組(zu)，如整(zheng)理(li)裝訂組(zu)、編碼錄入組(zu)、病(bing)案(an)(an)(an)復(fu)(fu)印組(zu)、醫(yi)(yi)療統(tong)計組(zu)、歸(gui)檔供應(ying)(ying)組(zu)等(deng)，確(que)定(ding)自(zi)己(ji)的(de)(de)(de)(de)(de)工作量，并(bing)建立獎(jiang)懲(cheng)制(zhi)度，如負責整(zheng)理(li)裝訂的(de)(de)(de)(de)(de)人(ren)員，未能及(ji)時(shi)(shi)錄入病(bing)案(an)(an)(an)影響使用(yong)的(de)(de)(de)(de)(de)、化驗單粘貼出(chu)錯、病(bing)案(an)(an)(an)填寫裝訂出(chu)錯等(deng)則相(xiang)對(dui)(dui)(dui)減分(fen)(fen)；如病(bing)案(an)(an)(an)復(fu)(fu)印組(zu)，服務(wu)(wu)態度好(hao)，無端受到患者的(de)(de)(de)(de)(de)刁難仍繼續履行(xing)(xing)(xing)(xing)職責等(deng)，應(ying)(ying)予以(yi)加分(fen)(fen)。除此之(zhi)外(wai)，還應(ying)(ying)對(dui)(dui)(dui)醫(yi)(yi)務(wu)(wu)人(ren)員的(de)(de)(de)(de)(de)勞動紀律、出(chu)勤(qin)、醫(yi)(yi)德醫(yi)(yi)風(feng)進行(xing)(xing)(xing)(xing)考核，嚴格按照(zhao)評(ping)分(fen)(fen)標準(zhun)進行(xing)(xing)(xing)(xing)評(ping)分(fen)(fen)，加減分(fen)(fen)時(shi)(shi)應(ying)(ying)注明(ming)相(xiang)應(ying)(ying)的(de)(de)(de)(de)(de)原(yuan)因。每月的(de)(de)(de)(de)(de)月末進行(xing)(xing)(xing)(xing)科內(nei)總結(jie)時(shi)(shi)，主任及(ji)護士長應(ying)(ying)根據(ju)考核的(de)(de)(de)(de)(de)評(ping)分(fen)(fen)對(dui)(dui)(dui)工作完成(cheng)較好(hao)的(de)(de)(de)(de)(de)人(ren)員予以(yi)獎(jiang)金激勵，對(dui)(dui)(dui)減分(fen)(fen)情況進行(xing)(xing)(xing)(xing)討(tao)論與(yu)分(fen)(fen)析(xi)。

1.3觀察指標

【摘(zhai)要(yao)(yao)(yao)】病案(an)(an)是指患者(zhe)在接受(shou)診療(liao)(liao)過程(cheng)中形成的(de)(de)(de)(de)(de)(de)詳(xiang)細病情記錄，包括醫(yi)(yi)護(hu)人(ren)員的(de)(de)(de)(de)(de)(de)病情診斷(duan)(duan)、醫(yi)(yi)藥(yao)處理(li)(li)(li)、檢查報告等數(shu)(shu)據信息，對(dui)醫(yi)(yi)院(yuan)和患者(zhe)而言(yan)其都有(you)重(zhong)要(yao)(yao)(yao)的(de)(de)(de)(de)(de)(de)參考意(yi)義。近幾年來，隨(sui)著醫(yi)(yi)療(liao)(liao)水平(ping)不斷(duan)(duan)提升(sheng)，醫(yi)(yi)院(yuan)病案(an)(an)的(de)(de)(de)(de)(de)(de)數(shu)(shu)量(liang)(liang)也逐日增多(duo)，如(ru)何在有(you)限的(de)(de)(de)(de)(de)(de)資源中強化(hua)對(dui)病案(an)(an)的(de)(de)(de)(de)(de)(de)管(guan)理(li)(li)(li)成為醫(yi)(yi)院(yuan)亟(ji)需(xu)解決的(de)(de)(de)(de)(de)(de)問題。良好的(de)(de)(de)(de)(de)(de)病案(an)(an)管(guan)理(li)(li)(li)體現醫(yi)(yi)療(liao)(liao)服(fu)務質(zhi)量(liang)(liang)，是衡量(liang)(liang)一所(suo)醫(yi)(yi)院(yuan)管(guan)理(li)(li)(li)水平(ping)的(de)(de)(de)(de)(de)(de)重(zhong)要(yao)(yao)(yao)參數(shu)(shu)，也是減少醫(yi)(yi)患糾紛，協調(diao)各部門工(gong)作的(de)(de)(de)(de)(de)(de)重(zhong)要(yao)(yao)(yao)內容(rong)。本(ben)次(ci)研究對(dui)醫(yi)(yi)院(yuan)病案(an)(an)管(guan)理(li)(li)(li)中存在的(de)(de)(de)(de)(de)(de)問題及(ji)所(suo)采取(qu)的(de)(de)(de)(de)(de)(de)對(dui)策進行了探討，希望能為相關工(gong)作人(ren)員提供借鑒。

【關鍵詞】醫院病(bing)案;管理;問題;對策

病(bing)(bing)(bing)(bing)案(an)(an)古稱“診籍”、“醫案(an)(an)”，隨著醫療改(gai)革的(de)(de)(de)推進，病(bing)(bing)(bing)(bing)案(an)(an)被不斷賦予新的(de)(de)(de)內(nei)涵，在(zai)新醫改(gai)的(de)(de)(de)背景(jing)下(xia)，醫院(yuan)醫療信息建設的(de)(de)(de)集(ji)成度越來越高(gao)。病(bing)(bing)(bing)(bing)案(an)(an)中記錄(lu)了(le)一個(ge)人的(de)(de)(de)既往(wang)病(bing)(bing)(bing)(bing)史、遺傳病(bing)(bing)(bing)(bing)史、各個(ge)階段(duan)的(de)(de)(de)病(bing)(bing)(bing)(bing)情及檢查結(jie)果、治療方法等信息，是(shi)醫生開展(zhan)工作，也(ye)是(shi)患者(zhe)了(le)解病(bing)(bing)(bing)(bing)情的(de)(de)(de)重要參(can)照物。完善的(de)(de)(de)病(bing)(bing)(bing)(bing)案(an)(an)不僅可滿(man)足(zu)醫院(yuan)管理和患者(zhe)需求(qiu)，在(zai)保險理賠(pei)、司法取證、醫患糾紛方面(mian)也(ye)具有重要作用。因(yin)此，為適(shi)應新的(de)(de)(de)形(xing)勢，不斷提高(gao)病(bing)(bing)(bing)(bing)案(an)(an)管理質量，對醫院(yuan)病(bing)(bing)(bing)(bing)案(an)(an)管理中存在(zai)的(de)(de)(de)問題進行剖(pou)析顯(xian)得十分必要[1]。

1醫院病(bing)案管理中存在(zai)的問(wen)題

1.1病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)意識與(yu)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)利用(yong)率(lv)有(you)(you)待(dai)提升(sheng)。現(xian)(xian)代醫(yi)(yi)(yi)療(liao)(liao)(liao)對(dui)(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)提出(chu)了(le)(le)新(xin)要(yao)求(qiu)，不(bu)(bu)(bu)(bu)(bu)僅(jin)是(shi)(shi)(shi)(shi)醫(yi)(yi)(yi)療(liao)(liao)(liao)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)的(de)(de)(de)(de)(de)整理(li)(li)(li)(li)歸類，更是(shi)(shi)(shi)(shi)醫(yi)(yi)(yi)院(yuan)循(xun)證醫(yi)(yi)(yi)學(xue)(xue)(xue)(xue)研究和(he)診療(liao)(liao)(liao)數(shu)據收(shou)集和(he)分(fen)(fen)析的(de)(de)(de)(de)(de)基(ji)礎(chu)(chu)。新(xin)醫(yi)(yi)(yi)改(gai)后各(ge)地市醫(yi)(yi)(yi)院(yuan)加(jia)強了(le)(le)醫(yi)(yi)(yi)療(liao)(liao)(liao)信(xin)(xin)(xin)(xin)息(xi)(xi)系(xi)統(tong)建設，但(dan)是(shi)(shi)(shi)(shi)仍(reng)然(ran)存(cun)在(zai)(zai)(zai)不(bu)(bu)(bu)(bu)(bu)少問(wen)題，對(dui)(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)意義認識不(bu)(bu)(bu)(bu)(bu)足(zu)，且病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)利用(yong)效率(lv)難以(yi)發揮最大(da)化。具體表現(xian)(xian)在(zai)(zai)(zai)以(yi)下幾個(ge)(ge)(ge)方(fang)(fang)(fang)面：首先(xian)，醫(yi)(yi)(yi)院(yuan)對(dui)(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)建設投入不(bu)(bu)(bu)(bu)(bu)足(zu)，致(zhi)使(shi)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)缺乏(fa)(fa)后備資(zi)金；其(qi)次，對(dui)(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)人(ren)(ren)員(yuan)的(de)(de)(de)(de)(de)教育(yu)培訓(xun)不(bu)(bu)(bu)(bu)(bu)達標；再次，對(dui)(dui)醫(yi)(yi)(yi)療(liao)(liao)(liao)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)的(de)(de)(de)(de)(de)利用(yong)度(du)不(bu)(bu)(bu)(bu)(bu)足(zu)，尤其(qi)是(shi)(shi)(shi)(shi)針對(dui)(dui)疑(yi)難雜(za)癥和(he)罕見(jian)(jian)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)例的(de)(de)(de)(de)(de)歸檔(dang)(dang)利用(yong)方(fang)(fang)(fang)面，對(dui)(dui)一(yi)(yi)些(xie)(xie)重(zhong)要(yao)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)的(de)(de)(de)(de)(de)開發和(he)挖掘不(bu)(bu)(bu)(bu)(bu)夠深刻，無形中浪(lang)費(fei)了(le)(le)學(xue)(xue)(xue)(xue)習資(zi)源(yuan)[2]。1.2醫(yi)(yi)(yi)院(yuan)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)制度(du)不(bu)(bu)(bu)(bu)(bu)健全，病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)分(fen)(fen)散(san)。目(mu)前醫(yi)(yi)(yi)院(yuan)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)主要(yao)有(you)(you)兩(liang)種形式(shi)(shi)：一(yi)(yi)種是(shi)(shi)(shi)(shi)把(ba)所(suo)有(you)(you)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)集中在(zai)(zai)(zai)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)室，另(ling)(ling)一(yi)(yi)種是(shi)(shi)(shi)(shi)由各(ge)個(ge)(ge)(ge)臨床(chuang)科室自行歸檔(dang)(dang)處(chu)理(li)(li)(li)(li)。這(zhe)兩(liang)種方(fang)(fang)(fang)式(shi)(shi)皆有(you)(you)各(ge)自的(de)(de)(de)(de)(de)問(wen)題，一(yi)(yi)方(fang)(fang)(fang)面各(ge)個(ge)(ge)(ge)科室對(dui)(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)資(zi)源(yuan)和(he)其(qi)他信(xin)(xin)(xin)(xin)息(xi)(xi)難以(yi)有(you)(you)效整合(he)，另(ling)(ling)一(yi)(yi)方(fang)(fang)(fang)面管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)的(de)(de)(de)(de)(de)分(fen)(fen)散(san)致(zhi)使(shi)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)模式(shi)(shi)缺乏(fa)(fa)統(tong)一(yi)(yi)標準(zhun)。各(ge)個(ge)(ge)(ge)科室檔(dang)(dang)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)人(ren)(ren)員(yuan)配備不(bu)(bu)(bu)(bu)(bu)合(he)理(li)(li)(li)(li)，大(da)部(bu)分(fen)(fen)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)室工(gong)作(zuo)(zuo)人(ren)(ren)員(yuan)是(shi)(shi)(shi)(shi)因(yin)年齡較大(da)或(huo)者(zhe)臨近退休從護(hu)(hu)理(li)(li)(li)(li)崗位上(shang)轉崗過來的(de)(de)(de)(de)(de)，或(huo)者(zhe)是(shi)(shi)(shi)(shi)醫(yi)(yi)(yi)院(yuan)關系(xi)戶，加(jia)大(da)了(le)(le)人(ren)(ren)員(yuan)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)的(de)(de)(de)(de)(de)難度(du)。醫(yi)(yi)(yi)院(yuan)內部(bu)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)學(xue)(xue)(xue)(xue)專(zhuan)(zhuan)業(ye)的(de)(de)(de)(de)(de)人(ren)(ren)才(cai)相對(dui)(dui)較少，一(yi)(yi)些(xie)(xie)在(zai)(zai)(zai)崗的(de)(de)(de)(de)(de)老(lao)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)員(yuan)工(gong)，雖然(ran)有(you)(you)專(zhuan)(zhuan)業(ye)的(de)(de)(de)(de)(de)臨床(chuang)護(hu)(hu)理(li)(li)(li)(li)知識，但(dan)是(shi)(shi)(shi)(shi)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)專(zhuan)(zhuan)業(ye)知識不(bu)(bu)(bu)(bu)(bu)足(zu)，知識面跟不(bu)(bu)(bu)(bu)(bu)上(shang)現(xian)(xian)代多媒體技術(shu)的(de)(de)(de)(de)(de)發展，與(yu)新(xin)醫(yi)(yi)(yi)改(gai)后的(de)(de)(de)(de)(de)醫(yi)(yi)(yi)院(yuan)信(xin)(xin)(xin)(xin)息(xi)(xi)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)要(yao)求(qiu)存(cun)在(zai)(zai)(zai)偏差(cha)[3]。1.3病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)人(ren)(ren)員(yuan)結(jie)(jie)構(gou)不(bu)(bu)(bu)(bu)(bu)合(he)理(li)(li)(li)(li)，專(zhuan)(zhuan)業(ye)性(xing)質(zhi)(zhi)不(bu)(bu)(bu)(bu)(bu)符。病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)需要(yao)專(zhuan)(zhuan)業(ye)人(ren)(ren)才(cai)出(chu)任，像(xiang)(xiang)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)學(xue)(xue)(xue)(xue)、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)學(xue)(xue)(xue)(xue)、醫(yi)(yi)(yi)學(xue)(xue)(xue)(xue)信(xin)(xin)(xin)(xin)息(xi)(xi)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)信(xin)(xin)(xin)(xin)息(xi)(xi)技術(shu)學(xue)(xue)(xue)(xue)、圖書館學(xue)(xue)(xue)(xue)、情報(bao)學(xue)(xue)(xue)(xue)等(deng)專(zhuan)(zhuan)業(ye)，對(dui)(dui)文件管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)、文書分(fen)(fen)類有(you)(you)系(xi)統(tong)化的(de)(de)(de)(de)(de)認識，但(dan)是(shi)(shi)(shi)(shi)從目(mu)前的(de)(de)(de)(de)(de)醫(yi)(yi)(yi)院(yuan)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)人(ren)(ren)力資(zi)源(yuan)情況來看，工(gong)作(zuo)(zuo)人(ren)(ren)員(yuan)結(jie)(jie)構(gou)不(bu)(bu)(bu)(bu)(bu)合(he)理(li)(li)(li)(li)，存(cun)在(zai)(zai)(zai)基(ji)礎(chu)(chu)理(li)(li)(li)(li)論、專(zhuan)(zhuan)業(ye)素養、文化程度(du)的(de)(de)(de)(de)(de)不(bu)(bu)(bu)(bu)(bu)足(zu)[4]。1.4臨床(chuang)醫(yi)(yi)(yi)護(hu)(hu)人(ren)(ren)員(yuan)對(dui)(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)質(zhi)(zhi)量不(bu)(bu)(bu)(bu)(bu)夠重(zhong)視。病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)記(ji)錄(lu)的(de)(de)(de)(de)(de)是(shi)(shi)(shi)(shi)患者(zhe)住(zhu)院(yuan)期間(jian)所(suo)接受的(de)(de)(de)(de)(de)一(yi)(yi)切檢查、治療(liao)(liao)(liao)、診斷(duan)數(shu)據，每個(ge)(ge)(ge)環節都需要(yao)注重(zhong)，但(dan)是(shi)(shi)(shi)(shi)很(hen)多醫(yi)(yi)(yi)護(hu)(hu)人(ren)(ren)員(yuan)對(dui)(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)的(de)(de)(de)(de)(de)處(chu)理(li)(li)(li)(li)不(bu)(bu)(bu)(bu)(bu)符合(he)標準(zhun)。首先(xian)，個(ge)(ge)(ge)別醫(yi)(yi)(yi)生對(dui)(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)歷(li)的(de)(de)(de)(de)(de)書寫(xie)潦草，難以(yi)辨認，雖然(ran)現(xian)(xian)在(zai)(zai)(zai)很(hen)多醫(yi)(yi)(yi)院(yuan)已(yi)經(jing)實(shi)行了(le)(le)電(dian)子病(bing)(bing)(bing)(bing)(bing)(bing)(bing)歷(li)，但(dan)還是(shi)(shi)(shi)(shi)存(cun)在(zai)(zai)(zai)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)歷(li)缺乏(fa)(fa)邏輯(ji)性(xing)的(de)(de)(de)(de)(de)問(wen)題。其(qi)次，專(zhuan)(zhuan)家會診記(ji)錄(lu)不(bu)(bu)(bu)(bu)(bu)完整或(huo)者(zhe)搶救記(ji)錄(lu)不(bu)(bu)(bu)(bu)(bu)全面，尤其(qi)是(shi)(shi)(shi)(shi)一(yi)(yi)些(xie)(xie)上(shang)級(ji)醫(yi)(yi)(yi)生的(de)(de)(de)(de)(de)查房和(he)處(chu)理(li)(li)(li)(li)意見(jian)(jian)沒有(you)(you)很(hen)好(hao)地記(ji)錄(lu)在(zai)(zai)(zai)冊。這(zhe)些(xie)(xie)行為(wei)都為(wei)醫(yi)(yi)(yi)療(liao)(liao)(liao)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)的(de)(de)(de)(de)(de)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)埋下隱患[5]。1.5病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)設施陳舊。如今醫(yi)(yi)(yi)院(yuan)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)已(yi)經(jing)走進了(le)(le)案(an)(an)(an)(an)(an)(an)(an)(an)（如圖1），但(dan)是(shi)(shi)(shi)(shi)對(dui)(dui)計(ji)算(suan)機(ji)技術(shu)的(de)(de)(de)(de)(de)利用(yong)程度(du)還有(you)(you)很(hen)大(da)提升(sheng)空間(jian)。一(yi)(yi)方(fang)(fang)(fang)面，計(ji)算(suan)機(ji)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)設備陳舊，像(xiang)(xiang)一(yi)(yi)些(xie)(xie)新(xin)的(de)(de)(de)(de)(de)條形識別碼、計(ji)算(suan)機(ji)光盤等(deng)未能利用(yong)；另(ling)(ling)一(yi)(yi)方(fang)(fang)(fang)面醫(yi)(yi)(yi)院(yuan)構(gou)建的(de)(de)(de)(de)(de)信(xin)(xin)(xin)(xin)息(xi)(xi)系(xi)統(tong)相對(dui)(dui)初級(ji)，在(zai)(zai)(zai)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)上(shang)沒有(you)(you)構(gou)建升(sheng)級(ji)版的(de)(de)(de)(de)(de)信(xin)(xin)(xin)(xin)息(xi)(xi)平臺。以(yi)上(shang)種種因(yin)素均(jun)制約了(le)(le)醫(yi)(yi)(yi)院(yuan)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)的(de)(de)(de)(de)(de)發展。

2解決對策

一(yi)、病案管理的主要信息為醫政管理提供依據

1．病(bing)案(an)(an)號(hao)管(guan)理:病(bing)案(an)(an)號(hao)是患者唯一識別號(hao)，病(bing)案(an)(an)室成(cheng)立已(yi)六(liu)十余年，保持病(bing)案(an)(an)號(hao)一人(ren)一號(hao)至今，通過病(bing)案(an)(an)號(hao)檢索病(bing)案(an)(an)信息廣泛應用。

2．病案借閱、復印(yin)管理:病案資料是(shi)患者(zhe)的(de)醫療(liao)記錄，對病案的(de)借閱或(huo)(huo)復印(yin)者(zhe)、借閱或(huo)(huo)復印(yin)方法等按照(zhao)國家(jia)規(gui)定(ding)嚴格執行。

3．病案的相(xiang)關資(zi)料:在醫政管理工(gong)作中，不論是(shi)統計病案中某項(xiang)數據(搶救成功率、平均(jun)住院(yuan)日等)，還是(shi)對收治(zhi)患者人數、療效(xiao)的講評，患者評殘、醫療保險等都要利用病案提供依據。院(yuan)領導發(fa)現我(wo)院(yuan)2014年上半年搶救成功率較低(di)，即加強管理，分析查找(zhao)原因，培(pei)訓(xun)搶救概念，規(gui)范首頁填寫等，下半年搶救成功率明顯上升。

4．醫療保險檢查(cha):醫保部門每月定(ding)期(qi)派人通(tong)過(guo)閱覽(lan)病案檢查(cha)醫保工作，根據醫保人員提出的問題，醫政管理(li)人員給(gei)予積極(ji)的配合，并合理(li)解(jie)決。

5．病案(an)書寫(xie)質(zhi)量(liang)(liang)(liang):病歷書寫(xie)質(zhi)量(liang)(liang)(liang)管(guan)(guan)理(li)(li)是病案(an)管(guan)(guan)理(li)(li)的(de)重(zhong)要部分，病案(an)書寫(xie)質(zhi)量(liang)(liang)(liang)直接(jie)影響醫(yi)政管(guan)(guan)理(li)(li)的(de)質(zhi)量(liang)(liang)(liang)，提(ti)示醫(yi)政管(guan)(guan)理(li)(li)對(dui)核心制度的(de)執行情(qing)況。同時(shi)病案(an)書寫(xie)質(zhi)量(liang)(liang)(liang)的(de)管(guan)(guan)理(li)(li)需(xu)要醫(yi)政管(guan)(guan)理(li)(li)制度的(de)制約。

1病案管理情況簡述

隨著病(bing)案管(guan)理的信息化，病(bing)案管(guan)理當中蘊含的組(zu)織系統、人力(li)資源管(guan)理、經濟(ji)效益等一系列的數據(ju)都被更加直觀的展(zhan)現(xian)在醫(yi)(yi)院(yuan)管(guan)理者的面(mian)前，對于(yu)醫(yi)(yi)院(yuan)未來的發(fa)展(zhan)發(fa)揮了(le)決策輔(fu)助作(zuo)用(yong)。一些大中型醫(yi)(yi)院(yuan)還建立起基于(yu)病(bing)案管(guan)理的病(bing)案數據(ju)庫，進(jin)而醫(yi)(yi)院(yuan)的整體業務工作(zuo)開展(zhan)更具實效性。

2病(bing)案管理(li)發(fa)展趨勢分析

病案管(guan)理已經逐漸成(cheng)為醫療機構最為重(zhong)要(yao)的(de)(de)(de)一項管(guan)理工作，提(ti)升病案管(guan)理的(de)(de)(de)整(zheng)體水平對于醫院而言(yan)無(wu)疑將是有效(xiao)推進(jin)醫療信息(xi)化發展的(de)(de)(de)重(zhong)要(yao)舉措(cuo)。進(jin)而全面帶動醫療服(fu)務的(de)(de)(de)科學化發展和高效(xiao)化發展。

2．1病(bing)(bing)(bing)案管(guan)(guan)理(li)(li)(li)(li)更(geng)偏重(zhong)于為(wei)醫院(yuan)管(guan)(guan)理(li)(li)(li)(li)而(er)(er)服務(wu)：醫院(yuan)管(guan)(guan)理(li)(li)(li)(li)工(gong)(gong)作(zuo)涉及到(dao)醫院(yuan)的(de)(de)方方面(mian)面(mian)，做(zuo)好日常管(guan)(guan)理(li)(li)(li)(li)工(gong)(gong)作(zuo)才能確保(bao)醫院(yuan)在(zai)診(zhen)(zhen)療(liao)(liao)和(he)護(hu)理(li)(li)(li)(li)等方面(mian)工(gong)(gong)作(zuo)上(shang)(shang)取(qu)得(de)預(yu)期效果。隨著病(bing)(bing)(bing)案管(guan)(guan)理(li)(li)(li)(li)的(de)(de)分類化發展(zhan)和(he)規范化發展(zhan)，病(bing)(bing)(bing)案管(guan)(guan)理(li)(li)(li)(li)的(de)(de)實際作(zuo)用(yong)更(geng)多直接體現在(zai)醫院(yuan)管(guan)(guan)理(li)(li)(li)(li)當(dang)中，為(wei)醫院(yuan)管(guan)(guan)理(li)(li)(li)(li)而(er)(er)服務(wu)。電子病(bing)(bing)(bing)案管(guan)(guan)理(li)(li)(li)(li)系(xi)統(tong)的(de)(de)應用(yong)，使(shi)患者的(de)(de)就診(zhen)(zhen)信息被實時(shi)保(bao)存(cun)到(dao)數據庫當(dang)中，不同的(de)(de)醫生能夠實時(shi)查(cha)詢到(dao)患者的(de)(de)就診(zhen)(zhen)信息和(he)診(zhen)(zhen)斷情況，因此減(jian)少了(le)(le)不必要的(de)(de)重(zhong)復診(zhen)(zhen)療(liao)(liao)行為(wei)，降(jiang)低了(le)(le)患者支出，同時(shi)也節約了(le)(le)醫療(liao)(liao)資源(yuan)。隨著社會保(bao)障體系(xi)的(de)(de)不斷完善(shan)，城鄉(xiang)醫療(liao)(liao)保(bao)險(xian)的(de)(de)覆蓋面(mian)越來越寬，現有的(de)(de)醫療(liao)(liao)體制(zhi)面(mian)臨深化改革(ge)的(de)(de)客觀要求。醫療(liao)(liao)機構的(de)(de)管(guan)(guan)理(li)(li)(li)(li)成(cheng)本在(zai)逐年上(shang)(shang)升(sheng)，醫療(liao)(liao)成(cheng)本的(de)(de)上(shang)(shang)升(sheng)既需要政府(fu)資金(jin)的(de)(de)投(tou)入彌(mi)補，同樣(yang)也會有一(yi)部分成(cheng)本轉嫁(jia)到(dao)患者身上(shang)(shang)。如何控(kong)制(zhi)醫療(liao)(liao)成(cheng)本已經成(cheng)為(wei)一(yi)個關(guan)鍵性問題。醫療(liao)(liao)改革(ge)要改變以藥(yao)養(yang)醫的(de)(de)錯誤(wu)模式，構建一(yi)個更(geng)為(wei)合理(li)(li)(li)(li)的(de)(de)醫療(liao)(liao)體系(xi)發展(zhan)框架，控(kong)制(zhi)醫療(liao)(liao)成(cheng)本的(de)(de)過度增長，在(zai)一(yi)定程度上(shang)(shang)取(qu)決于病(bing)(bing)(bing)案管(guan)(guan)理(li)(li)(li)(li)等相關(guan)工(gong)(gong)作(zuo)。病(bing)(bing)(bing)案管(guan)(guan)理(li)(li)(li)(li)為(wei)醫院(yuan)管(guan)(guan)理(li)(li)(li)(li)提供了(le)(le)基(ji)礎分析數據，進(jin)而(er)(er)使(shi)醫療(liao)(liao)資源(yuan)被更(geng)為(wei)合理(li)(li)(li)(li)的(de)(de)分配，提升(sheng)資源(yuan)的(de)(de)利用(yong)率，使(shi)患者能夠獲得(de)更(geng)為(wei)理(li)(li)(li)(li)想的(de)(de)醫療(liao)(liao)服務(wu)。

2．2病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)逐步納入醫(yi)(yi)學(xue)教(jiao)(jiao)育(yu)當(dang)中(zhong)(zhong)：隨著病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)工作(zuo)的(de)(de)越發(fa)重要(yao)(yao)，將病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)納入日常(chang)醫(yi)(yi)學(xue)教(jiao)(jiao)育(yu)當(dang)中(zhong)(zhong)已經成為關鍵(jian)之(zhi)舉。注重對病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)人(ren)(ren)才(cai)(cai)的(de)(de)培養與當(dang)前醫(yi)(yi)療(liao)發(fa)展有著內在(zai)密切的(de)(de)聯系。病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)學(xue)是一(yi)門綜(zong)合性學(xue)科，對于從事病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)人(ren)(ren)員的(de)(de)要(yao)(yao)求(qiu)(qiu)較(jiao)高。在(zai)國外一(yi)些(xie)醫(yi)(yi)學(xue)教(jiao)(jiao)育(yu)發(fa)達的(de)(de)國家(jia)當(dang)中(zhong)(zhong)，病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)學(xue)已經成為一(yi)門非常(chang)重要(yao)(yao)的(de)(de)學(xue)科，相關的(de)(de)醫(yi)(yi)療(liao)工作(zuo)人(ren)(ren)員在(zai)上崗(gang)之(zhi)前必須通過統一(yi)的(de)(de)考試(shi)，具備符合病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)實際(ji)工作(zuo)需要(yao)(yao)的(de)(de)能力，方能從事相關崗(gang)位。我國在(zai)病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)人(ren)(ren)才(cai)(cai)的(de)(de)培養方面(mian)(mian)與先(xian)進國家(jia)之(zhi)間存在(zai)一(yi)定的(de)(de)差距，在(zai)醫(yi)(yi)學(xue)教(jiao)(jiao)育(yu)當(dang)中(zhong)(zhong)，病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)并沒有被有效(xiao)突(tu)出，整(zheng)體(ti)色培訓(xun)培養效(xiao)果還不夠明顯。缺乏有效(xiao)的(de)(de)系統教(jiao)(jiao)學(xue)培養，我國醫(yi)(yi)療(liao)機構病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)人(ren)(ren)員的(de)(de)整(zheng)體(ti)水平(ping)和素質提升速度較(jiao)慢。目前結(jie)合實際(ji)需求(qiu)(qiu)，病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)教(jiao)(jiao)學(xue)已經逐步納入醫(yi)(yi)學(xue)教(jiao)(jiao)育(yu)當(dang)中(zhong)(zhong)，為病(bing)案(an)(an)(an)管(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)水平(ping)的(de)(de)全(quan)面(mian)(mian)提升提供保障。

1充分認識病案信(xin)息(xi)管理(li)的(de)作用

病(bing)案(an)信息是醫院檔案(an)信息的(de)重要組成部(bu)分，是現代醫院正常運轉的(de)工作(zuo)基礎，隨著國家《醫療事故(gu)處理條例》的(de)頒布，病(bing)案(an)工作(zuo)已引起了各(ge)級各(ge)類醫院的(de)普遍重視，病(bing)案(an)管理已從原(yuan)來(lai)的(de)單純服(fu)務型向學術型、經營(ying)型、社會服(fu)務型轉變。

1.1病(bing)歷檔案(an)(an)是(shi)(shi)醫(yi)(yi)院管(guan)(guan)理的(de)(de)信息庫。病(bing)歷檔案(an)(an)記(ji)載了每個病(bing)人的(de)(de)疾病(bing)情況、診療方法和效果，是(shi)(shi)臨床(chuang)實踐(jian)的(de)(de)全部原始(shi)記(ji)錄(lu)，也(ye)是(shi)(shi)醫(yi)(yi)院管(guan)(guan)理中(zhong)的(de)(de)重(zhong)要信息資料，是(shi)(shi)進行科學(xue)管(guan)(guan)理和醫(yi)(yi)師(shi)考核的(de)(de)重(zhong)要依據，也(ye)是(shi)(shi)醫(yi)(yi)院醫(yi)(yi)療業(ye)務統計的(de)(de)主要原始(shi)資料之(zhi)一(yi)。

1.2病(bing)案檔案是醫(yi)院臨床教(jiao)研工作的活教(jiao)材(cai)。一份(fen)內容完整的病(bing)歷(li)(li)檔案，是醫(yi)生對病(bing)癥(zheng)正確(que)診(zhen)斷和決定治(zhi)療(liao)(liao)方案不可或(huo)缺的重要(yao)依據，病(bing)人的病(bing)情存在(zai)許多(duo)相似或(huo)相近的癥(zheng)狀，特別(bie)是一些疑難雜癥(zheng)，這就需要(yao)參考(kao)過去的診(zhen)治(zhi)資料。通過對病(bing)歷(li)(li)檔案進行分(fen)(fen)析(xi)，綜合(he)分(fen)(fen)析(xi)病(bing)情，才能研究制(zhi)定出更(geng)加完善的診(zhen)斷治(zhi)療(liao)(liao)方案，使(shi)診(zhen)治(zhi)更(geng)加合(he)理，療(liao)(liao)效(xiao)更(geng)加明顯，從而進一步提高(gao)醫(yi)療(liao)(liao)質量和醫(yi)療(liao)(liao)水平。

1.3病(bing)案檔案是(shi)醫(yi)(yi)療(liao)糾(jiu)紛(fen)處(chu)理、傷(shang)殘評定(ding)、訴(su)訟案件(jian)調(diao)查的(de)重(zhong)要(yao)法律依(yi)據。病(bing)案檔案可(ke)(ke)以為(wei)醫(yi)(yi)療(liao)保險提供(gong)真實(shi)的(de)信(xin)息，是(shi)保險理賠(pei)的(de)可(ke)(ke)靠依(yi)據。在(zai)(zai)解決醫(yi)(yi)療(liao)糾(jiu)紛(fen)方(fang)面，它可(ke)(ke)以實(shi)現(xian)全面地反映病(bing)人住院期間的(de)就診(zhen)情況，成為(wei)保護病(bing)人、醫(yi)(yi)生和(he)醫(yi)(yi)院利益的(de)重(zhong)要(yao)記錄。在(zai)(zai)處(chu)理各種(zhong)肇事、事故和(he)傷(shang)殘鑒定(ding)時，必須根據病(bing)歷檔案來做檢查分析(xi)，才能推斷出(chu)責任之所在(zai)(zai)。

2強化病案(an)的管理力度

1病案、統計的概念(nian)及相互關系

醫(yi)(yi)(yi)院(yuan)(yuan)統(tong)(tong)計(ji)和(he)病案(an)(an)(an)管(guan)(guan)理(li)從(cong)表(biao)面上看，雖然是(shi)兩(liang)個相(xiang)對(dui)獨立的(de)(de)概(gai)念，但是(shi)它們(men)之(zhi)間卻有著(zhu)(zhu)千絲(si)萬縷(lv)的(de)(de)聯系，彼此間有著(zhu)(zhu)相(xiang)互(hu)說(shuo)明、相(xiang)互(hu)利用與(yu)監督(du)的(de)(de)關系，它們(men)都是(shi)醫(yi)(yi)(yi)院(yuan)(yuan)管(guan)(guan)理(li)不可缺少的(de)(de)重要內容。病案(an)(an)(an)指醫(yi)(yi)(yi)務人員記錄(lu)疾(ji)病診療(liao)過程的(de)(de)醫(yi)(yi)(yi)療(liao)性文(wen)件，它客(ke)觀地(di)、完整地(di)、連(lian)續地(di)記錄(lu)了患者的(de)(de)病情變化、診療(liao)經過、治療(liao)效(xiao)果及最(zui)終轉歸(gui)，是(shi)醫(yi)(yi)(yi)療(liao)、教學(xue)(xue)(xue)、科研的(de)(de)基(ji)礎(chu)資料(liao)，也是(shi)醫(yi)(yi)(yi)學(xue)(xue)(xue)科學(xue)(xue)(xue)的(de)(de)原始(shi)檔案(an)(an)(an)材料(liao)。而醫(yi)(yi)(yi)院(yuan)(yuan)大部(bu)分(fen)的(de)(de)統(tong)(tong)計(ji)工(gong)作則是(shi)對(dui)這些病案(an)(an)(an)原始(shi)資料(liao)進行收集、整理(li)、加工(gong)、錄(lu)入(ru)，最(zui)終生(sheng)成醫(yi)(yi)(yi)院(yuan)(yuan)的(de)(de)各種(zhong)統(tong)(tong)計(ji)報表(biao)。統(tong)(tong)計(ji)是(shi)表(biao)述病案(an)(an)(an)的(de)(de)手段，它把病案(an)(an)(an)提(ti)供的(de)(de)散在(zai)的(de)(de)無(wu)規(gui)律可循(xun)的(de)(de)原始(shi)資料(liao)，經過科學(xue)(xue)(xue)的(de)(de)分(fen)析處(chu)理(li)后，使之(zhi)成為行之(zhi)有效(xiao)的(de)(de)信(xin)息，在(zai)醫(yi)(yi)(yi)院(yuan)(yuan)的(de)(de)經濟運(yun)行中(zhong)發揮著(zhu)(zhu)信(xin)息、咨詢和(he)監督(du)三大職能。一份完整、規(gui)范、詳細、準確的(de)(de)病案(an)(an)(an)記錄(lu)對(dui)醫(yi)(yi)(yi)院(yuan)(yuan)住(zhu)院(yuan)(yuan)、疾(ji)病分(fen)類等統(tong)(tong)計(ji)報表(biao)有著(zhu)(zhu)重要的(de)(de)作用，它直接影響(xiang)到統(tong)(tong)計(ji)報表(biao)的(de)(de)質量(liang)。

2病案(an)統計在醫院管理中(zhong)發(fa)揮著(zhu)重要作用

病案(an)不僅是各(ge)(ge)類醫(yi)療業務(wu)統(tong)計(ji)資料科(ke)學、可(ke)(ke)靠的(de)原始依據，而且在管理工(gong)作(zuo)中需(xu)要的(de)許多信息(xi)也可(ke)(ke)以(yi)從(cong)病案(an)中查取。通過對(dui)病案(an)資料進(jin)行(xing)深加(jia)工(gong)，運用統(tong)計(ji)學理論和(he)方(fang)法進(jin)行(xing)分析，可(ke)(ke)以(yi)制(zhi)定出(chu)醫(yi)院(yuan)的(de)工(gong)作(zuo)計(ji)劃和(he)長期規劃；可(ke)(ke)以(yi)分析出(chu)醫(yi)院(yuan)的(de)工(gong)作(zuo)效率和(he)醫(yi)療質量(liang)、業務(wu)水平、醫(yi)療效果、服務(wu)態度和(he)經濟(ji)效益等；可(ke)(ke)以(yi)監(jian)測和(he)檢查出(chu)醫(yi)院(yuan)各(ge)(ge)部門(men)、各(ge)(ge)科(ke)室、各(ge)(ge)環節的(de)工(gong)作(zuo)，考核醫(yi)務(wu)人(ren)員；可(ke)(ke)以(yi)對(dui)醫(yi)院(yuan)工(gong)作(zuo)進(jin)行(xing)質量(liang)分析和(he)經濟(ji)評估，指出(chu)醫(yi)療服務(wu)工(gong)作(zuo)存在的(de)問題，并提(ti)出(chu)改進(jin)措施(shi)。

2.1病(bing)案統計(ji)(ji)(ji)是(shi)(shi)醫(yi)(yi)(yi)院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)管理(li)的(de)(de)一個重要(yao)組成部分，為醫(yi)(yi)(yi)院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)的(de)(de)經(jing)(jing)(jing)營管理(li)決(jue)策提供(gong)了(le)可靠(kao)的(de)(de)依據。科(ke)學(xue)合(he)理(li)的(de)(de)決(jue)策是(shi)(shi)醫(yi)(yi)(yi)院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)管理(li)的(de)(de)基礎和核心。所謂醫(yi)(yi)(yi)院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)宏觀決(jue)策就是(shi)(shi)從醫(yi)(yi)(yi)院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)宏觀經(jing)(jing)(jing)濟(ji)發(fa)展(zhan)(zhan)的(de)(de)總(zong)體規劃(hua)出發(fa)，研究并制(zhi)定整個醫(yi)(yi)(yi)院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)發(fa)展(zhan)(zhan)的(de)(de)目(mu)(mu)標、戰略和方針政策，它(ta)對(dui)提高醫(yi)(yi)(yi)院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)的(de)(de)社會效(xiao)益和經(jing)(jing)(jing)濟(ji)效(xiao)益有著(zhu)重要(yao)的(de)(de)意義[2]。每年(nian)(nian)年(nian)(nian)初，醫(yi)(yi)(yi)院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)都(dou)要(yao)制(zhi)訂新一年(nian)(nian)的(de)(de)工作計(ji)(ji)(ji)劃(hua)，“醫(yi)(yi)(yi)院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)業(ye)務發(fa)展(zhan)(zhan)目(mu)(mu)標”是(shi)(shi)重要(yao)的(de)(de)一項內容，其中必(bi)定要(yao)涉及(ji)到“總(zong)診療人(ren)(ren)次數(shu)”、“出院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)人(ren)(ren)數(shu)”、“手術人(ren)(ren)次”、“總(zong)業(ye)務收(shou)入(ru)”等(deng)統計(ji)(ji)(ji)指標。2012年(nian)(nian)本院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)的(de)(de)目(mu)(mu)標是(shi)(shi)“力爭達到門急(ji)診患者(zhe)(zhe)65萬人(ren)(ren)次，出院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)患者(zhe)(zhe)1.5萬人(ren)(ren)次，手術患者(zhe)(zhe)5000人(ren)(ren)次，總(zong)業(ye)務收(shou)入(ru)2.5億元。”這一目(mu)(mu)標就是(shi)(shi)根據2011年(nian)(nian)統計(ji)(ji)(ji)數(shu)據匯總(zong)，經(jing)(jing)(jing)過分析(xi)比較后才制(zhi)訂出來的(de)(de)，從而保證(zheng)了(le)醫(yi)(yi)(yi)院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)發(fa)展(zhan)(zhan)目(mu)(mu)標的(de)(de)科(ke)學(xue)性、先進性和可靠(kao)性。所以(yi)，病(bing)案統計(ji)(ji)(ji)信息是(shi)(shi)否到位直(zhi)接影響(xiang)到醫(yi)(yi)(yi)院(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)(yuan)的(de)(de)決(jue)策正(zheng)確(que)與否。

2.2為醫(yi)院(yuan)(yuan)科(ke)(ke)室(shi)(shi)(shi)(shi)管(guan)(guan)(guan)理(li)(li)提(ti)供信息(xi)反(fan)饋(kui)臨(lin)(lin)(lin)床(chuang)科(ke)(ke)室(shi)(shi)(shi)(shi)是組成(cheng)醫(yi)院(yuan)(yuan)的(de)基本(ben)(ben)單元，臨(lin)(lin)(lin)床(chuang)科(ke)(ke)室(shi)(shi)(shi)(shi)管(guan)(guan)(guan)理(li)(li)是醫(yi)院(yuan)(yuan)管(guan)(guan)(guan)理(li)(li)的(de)核心和(he)(he)主(zhu)體(ti)。目前(qian)，在我國醫(yi)院(yuan)(yuan)分級(ji)管(guan)(guan)(guan)理(li)(li)的(de)有關(guan)規定(ding)和(he)(he)要(yao)求中，諸多的(de)醫(yi)療統計指(zhi)(zhi)標(biao)(biao)大(da)部分與臨(lin)(lin)(lin)床(chuang)科(ke)(ke)室(shi)(shi)(shi)(shi)有關(guan)。通(tong)過對病(bing)案(an)信息(xi)資源進行(xing)統計指(zhi)(zhi)標(biao)(biao)分析，“科(ke)(ke)室(shi)(shi)(shi)(shi)出(chu)入(ru)院(yuan)(yuan)人(ren)數(shu)”、“病(bing)床(chuang)使用(yong)(yong)率(lv)(lv)”、“床(chuang)位周轉率(lv)(lv)”、“術前(qian)住院(yuan)(yuan)天數(shu)”、“平均住院(yuan)(yuan)日”、“藥費比例及單病(bing)種(zhong)費用(yong)(yong)”等均是臨(lin)(lin)(lin)床(chuang)科(ke)(ke)室(shi)(shi)(shi)(shi)工(gong)作效(xiao)率(lv)(lv)和(he)(he)經濟管(guan)(guan)(guan)理(li)(li)的(de)體(ti)現(xian)[3]。例如：（1）通(tong)過對所有出(chu)院(yuan)(yuan)患者疾病(bing)的(de)分析，及時發現(xian)問題(ti)實施必要(yao)的(de)調(diao)整(zheng)和(he)(he)控制(zhi)，提(ti)高治愈率(lv)(lv)，縮短(duan)平均住院(yuan)(yuan)床(chuang)日，提(ti)高病(bing)床(chuang)周轉次數(shu)，有利于減少患者的(de)住院(yuan)(yuan)費用(yong)(yong)[4]；（2）為杜絕重(zhong)大(da)醫(yi)院(yuan)(yuan)感(gan)染事件(jian)和(he)(he)醫(yi)院(yuan)(yuan)感(gan)染暴發流行(xing)事件(jian)發生，要(yao)求本(ben)(ben)院(yuan)(yuan)科(ke)(ke)室(shi)(shi)(shi)(shi)達(da)到無(wu)菌(jun)手(shou)術切(qie)口感(gan)染率(lv)(lv)<1.5%，無(wu)菌(jun)手(shou)術切(qie)口甲級(ji)愈合率(lv)(lv)>97%，每月對科(ke)(ke)室(shi)(shi)(shi)(shi)進行(xing)數(shu)據監院(yuan)(yuan)控，一旦(dan)發現(xian)超標(biao)(biao)，立即通(tong)知院(yuan)(yuan)感(gan)科(ke)(ke)采取相應措(cuo)施，把醫(yi)院(yuan)(yuan)感(gan)染的(de)不良苗頭扼(e)殺(sha)在搖籃中；（3）對藥品(pin)比率(lv)(lv)超標(biao)(biao)的(de)科(ke)(ke)室(shi)(shi)(shi)(shi)，及時提(ti)醒(xing)科(ke)(ke)主(zhu)任進行(xing)全(quan)面(mian)控制(zhi)，使科(ke)(ke)室(shi)(shi)(shi)(shi)和(he)(he)醫(yi)務(wu)人(ren)員免除了(le)不必要(yao)的(de)經濟懲(cheng)罰。因(yin)此(ci)，病(bing)案(an)管(guan)(guan)(guan)理(li)(li)信息(xi)反(fan)饋(kui)成(cheng)了(le)科(ke)(ke)室(shi)(shi)(shi)(shi)管(guan)(guan)(guan)理(li)(li)的(de)指(zhi)(zhi)南針。

摘要(yao)：在醫療系(xi)統當中，對病(bing)案(an)(an)管理(li)是(shi)十分重要(yao)的(de)，因為在病(bing)案(an)(an)當中會(hui)記載(zai)著一些臨床的(de)經驗以(yi)及醫療器具的(de)使(shi)用等情況(kuang)，這(zhe)些對于醫學研(yan)究(jiu)都有著重要(yao)作用。該文簡單介(jie)紹新技(ji)術在病(bing)案(an)(an)管理(li)中的(de)工作性質，并(bing)對新技(ji)術在病(bing)案(an)(an)管理(li)中的(de)應用進(jin)行具體的(de)論(lun)述。

關(guan)鍵(jian)詞：新(xin)技術；病案管理(li)；論(lun)述；應(ying)用(yong)

病(bing)(bing)(bing)案(an)(an)是(shi)(shi)醫(yi)務人(ren)員工(gong)(gong)(gong)作(zuo)中記(ji)錄(lu)患者(zhe)(zhe)診療過程的(de)(de)(de)重要(yao)文件，無論(lun)是(shi)(shi)對于(yu)患者(zhe)(zhe)而言，還是(shi)(shi)對于(yu)醫(yi)療工(gong)(gong)(gong)作(zuo)者(zhe)(zhe)而言，病(bing)(bing)(bing)案(an)(an)管(guan)理(li)工(gong)(gong)(gong)作(zuo)都是(shi)(shi)至關(guan)重要(yao)的(de)(de)(de)[1-2]。在(zai)傳統(tong)(tong)的(de)(de)(de)病(bing)(bing)(bing)案(an)(an)管(guan)理(li)當中，都是(shi)(shi)采取紙質資料來保(bao)(bao)存(cun)(cun)患者(zhe)(zhe)的(de)(de)(de)病(bing)(bing)(bing)案(an)(an)，面對快速增長的(de)(de)(de)病(bing)(bing)(bing)案(an)(an)，這樣的(de)(de)(de)保(bao)(bao)存(cun)(cun)手(shou)段不(bu)易于(yu)長時間的(de)(de)(de)保(bao)(bao)存(cun)(cun)，而且(qie)不(bu)利于(yu)日常使用。在(zai)現如今的(de)(de)(de)高科技社會當中，為(wei)解(jie)決上述保(bao)(bao)存(cun)(cun)及使用的(de)(de)(de)難題，已經出現了(le)(le)電子病(bing)(bing)(bing)案(an)(an)系統(tong)(tong)及病(bing)(bing)(bing)案(an)(an)掃描(miao)系統(tong)(tong)，這些系統(tong)(tong)的(de)(de)(de)推出為(wei)病(bing)(bing)(bing)案(an)(an)的(de)(de)(de)管(guan)理(li)提(ti)供了(le)(le)很大的(de)(de)(de)幫助，不(bu)僅(jin)可(ke)以(yi)(yi)減少病(bing)(bing)(bing)案(an)(an)管(guan)理(li)工(gong)(gong)(gong)作(zuo)者(zhe)(zhe)的(de)(de)(de)工(gong)(gong)(gong)作(zuo)強(qiang)度，而且(qie)可(ke)以(yi)(yi)提(ti)升工(gong)(gong)(gong)作(zuo)效率[3]。

1新技術(shu)在病案管理中的性質

新技術在病(bing)(bing)案(an)(an)(an)管(guan)理(li)(li)(li)工(gong)作(zuo)(zuo)中應用較為普遍的(de)(de)是(shi)(shi)病(bing)(bing)案(an)(an)(an)紙質掃描，根(gen)據(ju)掃描病(bing)(bing)案(an)(an)(an)來實現(xian)網(wang)絡化的(de)(de)管(guan)理(li)(li)(li)，這種(zhong)(zhong)先(xian)進的(de)(de)管(guan)理(li)(li)(li)技術能夠為病(bing)(bing)案(an)(an)(an)管(guan)理(li)(li)(li)提供更(geng)多的(de)(de)保障。病(bing)(bing)案(an)(an)(an)通過掃描可(ke)以實現(xian)長期的(de)(de)保存，一旦有所需求，醫(yi)護(hu)工(gong)作(zuo)(zuo)者(zhe)可(ke)以在第一時間將病(bing)(bing)案(an)(an)(an)抽調出來，進行審閱，這種(zhong)(zhong)通過掃描技術的(de)(de)病(bing)(bing)案(an)(an)(an)保存手段，也就(jiu)是(shi)(shi)電子病(bing)(bing)案(an)(an)(an)的(de)(de)一種(zhong)(zhong)表(biao)現(xian)形(xing)式，電子病(bing)(bing)案(an)(an)(an)主(zhu)要(yao)是(shi)(shi)與醫(yi)院(yuan)管(guan)理(li)(li)(li)信息(xi)系(xi)統系(xi)統集成，包括醫(yi)學(xue)圖像處理(li)(li)(li)系(xi)統、醫(yi)學(xue)病(bing)(bing)例系(xi)統以及醫(yi)學(xue)檢驗(yan)系(xi)統等，這些系(xi)統在病(bing)(bing)案(an)(an)(an)管(guan)理(li)(li)(li)中都發(fa)揮著重要(yao)的(de)(de)作(zuo)(zuo)用[4]。

2新技(ji)術在病(bing)案(an)管理中(zhong)的應用

摘要：目的(de)探究醫院(yuan)(yuan)精(jing)(jing)細(xi)化(hua)(hua)(hua)管(guan)理(li)(li)(li)(li)(li)運(yun)用(yong)于病(bing)(bing)案(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)管(guan)理(li)(li)(li)(li)(li)的(de)實(shi)(shi)踐方(fang)法與實(shi)(shi)踐效果。方(fang)法2018年1月(yue)(yue)起我(wo)(wo)院(yuan)(yuan)緊抓病(bing)(bing)案(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)管(guan)理(li)(li)(li)(li)(li)，將醫院(yuan)(yuan)精(jing)(jing)細(xi)化(hua)(hua)(hua)管(guan)理(li)(li)(li)(li)(li)運(yun)用(yong)于病(bing)(bing)案(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)管(guan)理(li)(li)(li)(li)(li)中，采(cai)取(qu)一系(xi)列措(cuo)施(shi)(shi)落實(shi)(shi)這些(xie)管(guan)理(li)(li)(li)(li)(li)措(cuo)施(shi)(shi)。對比(bi)實(shi)(shi)施(shi)(shi)精(jing)(jing)細(xi)化(hua)(hua)(hua)病(bing)(bing)案(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)管(guan)理(li)(li)(li)(li)(li)之前(qian)（2017年1月(yue)(yue)-2017年12月(yue)(yue)）與實(shi)(shi)施(shi)(shi)病(bing)(bing)案(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)精(jing)(jing)細(xi)化(hua)(hua)(hua)管(guan)理(li)(li)(li)(li)(li)之后（2018年1月(yue)(yue)-2018年12月(yue)(yue)）的(de)實(shi)(shi)踐效果。結(jie)果病(bing)(bing)案(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)管(guan)理(li)(li)(li)(li)(li)實(shi)(shi)施(shi)(shi)精(jing)(jing)細(xi)化(hua)(hua)(hua)管(guan)理(li)(li)(li)(li)(li)后，我(wo)(wo)院(yuan)(yuan)的(de)病(bing)(bing)案(an)(an)(an)(an)歸檔正確(que)率(lv)（100.00%）、ICD編碼正確(que)率(lv)（91.26%）、病(bing)(bing)案(an)(an)(an)(an)首頁合格率(lv)（98.84%）、病(bing)(bing)案(an)(an)(an)(an)3日回(hui)收(shou)率(lv)（96.19%）均較(jiao)實(shi)(shi)施(shi)(shi)前(qian)顯(xian)(xian)著上升(sheng)；我(wo)(wo)院(yuan)(yuan)的(de)借閱(yue)病(bing)(bing)案(an)(an)(an)(an)按(an)時歸還率(lv)（98.27%）較(jiao)實(shi)(shi)施(shi)(shi)前(qian)顯(xian)(xian)著上升(sheng)（54.20%）；我(wo)(wo)院(yuan)(yuan)的(de)病(bing)(bing)案(an)(an)(an)(an)服務投訴率(lv)（0.01%）較(jiao)實(shi)(shi)施(shi)(shi)前(qian)（0.52%）降低（P均<0.05）。結(jie)論病(bing)(bing)案(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)管(guan)理(li)(li)(li)(li)(li)過(guo)程中采(cai)用(yong)精(jing)(jing)細(xi)化(hua)(hua)(hua)管(guan)理(li)(li)(li)(li)(li)式提高病(bing)(bing)案(an)(an)(an)(an)的(de)管(guan)理(li)(li)(li)(li)(li)質量、提高病(bing)(bing)案(an)(an)(an)(an)管(guan)理(li)(li)(li)(li)(li)規范性(xing)、確(que)保病(bing)(bing)例(li)安全的(de)有效方(fang)式，經(jing)過(guo)一系(xi)列管(guan)理(li)(li)(li)(li)(li)措(cuo)施(shi)(shi)，我(wo)(wo)院(yuan)(yuan)的(de)病(bing)(bing)案(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)管(guan)理(li)(li)(li)(li)(li)質量得到提高，其實(shi)(shi)踐效果顯(xian)(xian)著。

關鍵詞：精細化管(guan)理；病案信息管(guan)理；實(shi)踐措施；管(guan)理效果(guo)

病(bing)(bing)案是醫(yi)(yi)療(liao)信(xin)(xin)息的(de)(de)(de)重(zhong)(zhong)要(yao)(yao)載體，醫(yi)(yi)療(liao)改革進程不斷推進的(de)(de)(de)當前，病(bing)(bing)案信(xin)(xin)息已經(jing)不再(zai)局限于(yu)法(fa)律憑證(zheng)(zheng)、科研、教(jiao)學、醫(yi)(yi)療(liao)等方面，病(bing)(bing)案信(xin)(xin)息也成為(wei)了對醫(yi)(yi)院(yuan)(yuan)的(de)(de)(de)醫(yi)(yi)療(liao)質量(liang)做(zuo)出評價的(de)(de)(de)重(zhong)(zhong)要(yao)(yao)標(biao)準，是醫(yi)(yi)院(yuan)(yuan)提高(gao)(gao)管理(li)水(shui)平(ping)的(de)(de)(de)得(de)(de)力助手，也是醫(yi)(yi)保支付的(de)(de)(de)有(you)效抓手，因此病(bing)(bing)案信(xin)(xin)息管理(li)工作就顯得(de)(de)更為(wei)重(zhong)(zhong)要(yao)(yao)[1,2]。為(wei)提高(gao)(gao)醫(yi)(yi)院(yuan)(yuan)病(bing)(bing)案信(xin)(xin)息管理(li)水(shui)平(ping)，我院(yuan)(yuan)將精(jing)細化管理(li)運(yun)用于(yu)病(bing)(bing)案信(xin)(xin)息管理(li)中(zhong)，經(jing)實踐證(zheng)(zheng)明運(yun)用效果顯著(zhu)，報告如下。

1資料與方法

1.1資(zi)料(liao)來源。實(shi)(shi)(shi)施病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)(xi)精(jing)(jing)(jing)(jing)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)前(qian)(qian)（2017年(nian)1月(yue)(yue)-2017年(nian)12月(yue)(yue)）與(yu)(yu)(yu)(yu)(yu)實(shi)(shi)(shi)施病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)(xi)精(jing)(jing)(jing)(jing)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)后(hou)（2018年(nian)1月(yue)(yue)-2018年(nian)12月(yue)(yue)）兩個(ge)階段(duan)的(de)(de)(de)(de)(de)(de)(de)(de)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)為(wei)(wei)(wei)(wei)研(yan)究對(dui)象(xiang)(xiang)，對(dui)我院(yuan)(yuan)的(de)(de)(de)(de)(de)(de)(de)(de)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)質(zhi)(zhi)(zhi)量(liang)進(jin)行(xing)(xing)回(hui)(hui)(hui)顧(gu)性(xing)(xing)分(fen)(fen)(fen)析。從(cong)(cong)(cong)實(shi)(shi)(shi)施前(qian)(qian)后(hou)各(ge)(ge)(ge)(ge)選(xuan)取出(chu)(chu)(chu)(chu)院(yuan)(yuan)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)15,000份(fen)(fen)，對(dui)比管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)質(zhi)(zhi)(zhi)量(liang)。1.2方(fang)法(fa)。2018年(nian)1月(yue)(yue)起(qi)，我院(yuan)(yuan)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)科(ke)(ke)(ke)(ke)(ke)的(de)(de)(de)(de)(de)(de)(de)(de)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)中(zhong)引入(ru)精(jing)(jing)(jing)(jing)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)，以(yi)(yi)(yi)(yi)(yi)“精(jing)(jing)(jing)(jing)、準(zhun)、細(xi)(xi)(xi)、嚴”作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)為(wei)(wei)(wei)(wei)指導(dao)，將(jiang)精(jing)(jing)(jing)(jing)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)落(luo)實(shi)(shi)(shi)于(yu)時(shi)間節(jie)(jie)點(dian)(dian)、業(ye)(ye)務(wu)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)制(zhi)(zhi)度(du)以(yi)(yi)(yi)(yi)(yi)及(ji)(ji)(ji)(ji)崗(gang)(gang)位(wei)(wei)(wei)職(zhi)(zhi)(zhi)責等(deng)(deng)(deng)操(cao)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)與(yu)(yu)(yu)(yu)(yu)執(zhi)行(xing)(xing)中(zhong)，進(jin)而(er)(er)為(wei)(wei)(wei)(wei)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)的(de)(de)(de)(de)(de)(de)(de)(de)團(tuan)隊密切合作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)、工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)高(gao)質(zhi)(zhi)(zhi)量(liang)完成(cheng)(cheng)、管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)科(ke)(ke)(ke)(ke)(ke)學(xue)(xue)(xue)等(deng)(deng)(deng)提(ti)(ti)(ti)(ti)供(gong)保障。具體管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)實(shi)(shi)(shi)施方(fang)法(fa)如(ru)下。1.2.1出(chu)(chu)(chu)(chu)臺工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)制(zhi)(zhi)度(du)。為(wei)(wei)(wei)(wei)了(le)(le)確(que)(que)(que)保我院(yuan)(yuan)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)科(ke)(ke)(ke)(ke)(ke)進(jin)行(xing)(xing)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)時(shi)能(neng)(neng)有章可(ke)循，病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)科(ke)(ke)(ke)(ke)(ke)對(dui)過(guo)去存在的(de)(de)(de)(de)(de)(de)(de)(de)問題進(jin)行(xing)(xing)了(le)(le)總(zong)結(jie)(jie)與(yu)(yu)(yu)(yu)(yu)深刻反思，尋找工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)過(guo)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)中(zhong)存在的(de)(de)(de)(de)(de)(de)(de)(de)盲點(dian)(dian)與(yu)(yu)(yu)(yu)(yu)問題，立(li)足于(yu)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)科(ke)(ke)(ke)(ke)(ke)的(de)(de)(de)(de)(de)(de)(de)(de)實(shi)(shi)(shi)際(ji)情(qing)(qing)況(kuang)(kuang)(kuang)(kuang)與(yu)(yu)(yu)(yu)(yu)醫(yi)院(yuan)(yuan)的(de)(de)(de)(de)(de)(de)(de)(de)信(xin)息(xi)(xi)(xi)(xi)化(hua)(hua)(hua)(hua)建(jian)(jian)設(she)水平，對(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)制(zhi)(zhi)度(du)予(yu)(yu)以(yi)(yi)(yi)(yi)(yi)建(jian)(jian)立(li)、健全。出(chu)(chu)(chu)(chu)臺的(de)(de)(de)(de)(de)(de)(de)(de)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)制(zhi)(zhi)度(du)涵蓋(gai)消防應急預案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)、封存制(zhi)(zhi)度(du)、借(jie)(jie)閱(yue)制(zhi)(zhi)度(du)、隱私保護制(zhi)(zhi)度(du)、庫房管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)制(zhi)(zhi)度(du)、復印服務(wu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)制(zhi)(zhi)度(du)、查閱(yue)制(zhi)(zhi)度(du)、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)首(shou)頁(ye)(ye)(ye)專項管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)制(zhi)(zhi)度(du)、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)交接制(zhi)(zhi)度(du)以(yi)(yi)(yi)(yi)(yi)及(ji)(ji)(ji)(ji)回(hui)(hui)(hui)收(shou)(shou)(shou)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)制(zhi)(zhi)度(du)等(deng)(deng)(deng)[3]。病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)科(ke)(ke)(ke)(ke)(ke)同時(shi)強化(hua)(hua)(hua)(hua)對(dui)臨床醫(yi)師的(de)(de)(de)(de)(de)(de)(de)(de)培(pei)(pei)(pei)訓，成(cheng)(cheng)立(li)了(le)(le)規(gui)培(pei)(pei)(pei)生、進(jin)修生以(yi)(yi)(yi)(yi)(yi)及(ji)(ji)(ji)(ji)新入(ru)職(zhi)(zhi)(zhi)醫(yi)師的(de)(de)(de)(de)(de)(de)(de)(de)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)制(zhi)(zhi)度(du)的(de)(de)(de)(de)(de)(de)(de)(de)學(xue)(xue)(xue)習(xi)機(ji)制(zhi)(zhi)，從(cong)(cong)(cong)而(er)(er)確(que)(que)(que)保這些新入(ru)職(zhi)(zhi)(zhi)醫(yi)師能(neng)(neng)熟練掌握(wo)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)制(zhi)(zhi)度(du)。1.2.2對(dui)崗(gang)(gang)位(wei)(wei)(wei)內(nei)容與(yu)(yu)(yu)(yu)(yu)職(zhi)(zhi)(zhi)責予(yu)(yu)以(yi)(yi)(yi)(yi)(yi)明(ming)(ming)(ming)確(que)(que)(que)。（1）病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)科(ke)(ke)(ke)(ke)(ke)組(zu)織全體成(cheng)(cheng)員(yuan)(yuan)對(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)的(de)(de)(de)(de)(de)(de)(de)(de)內(nei)容、標準(zhun)以(yi)(yi)(yi)(yi)(yi)及(ji)(ji)(ji)(ji)項目等(deng)(deng)(deng)予(yu)(yu)以(yi)(yi)(yi)(yi)(yi)討(tao)論梳(shu)理(li)(li)(li)(li)(li)，對(dui)崗(gang)(gang)位(wei)(wei)(wei)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)內(nei)容做(zuo)出(chu)(chu)(chu)(chu)了(le)(le)明(ming)(ming)(ming)確(que)(que)(que)的(de)(de)(de)(de)(de)(de)(de)(de)劃分(fen)(fen)(fen)，其中(zhong)包(bao)(bao)括(kuo)(kuo)復印、供(gong)應、歸(gui)檔(dang)、質(zhi)(zhi)(zhi)量(liang)控(kong)制(zhi)(zhi)、統計(ji)、檔(dang)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)首(shou)頁(ye)(ye)(ye)錄(lu)入(ru)編碼以(yi)(yi)(yi)(yi)(yi)及(ji)(ji)(ji)(ji)回(hui)(hui)(hui)收(shou)(shou)(shou)整理(li)(li)(li)(li)(li)等(deng)(deng)(deng)。（2）對(dui)崗(gang)(gang)位(wei)(wei)(wei)職(zhi)(zhi)(zhi)責予(yu)(yu)以(yi)(yi)(yi)(yi)(yi)明(ming)(ming)(ming)確(que)(que)(que)，明(ming)(ming)(ming)確(que)(que)(que)提(ti)(ti)(ti)(ti)出(chu)(chu)(chu)(chu)了(le)(le)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)各(ge)(ge)(ge)(ge)崗(gang)(gang)位(wei)(wei)(wei)的(de)(de)(de)(de)(de)(de)(de)(de)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)銜(xian)接要(yao)(yao)求(qiu)、工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)要(yao)(yao)求(qiu)以(yi)(yi)(yi)(yi)(yi)及(ji)(ji)(ji)(ji)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)職(zhi)(zhi)(zhi)責等(deng)(deng)(deng)，先(xian)后(hou)建(jian)(jian)立(li)了(le)(le)復印、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)歸(gui)檔(dang)、質(zhi)(zhi)(zhi)量(liang)控(kong)制(zhi)(zhi)、統計(ji)崗(gang)(gang)位(wei)(wei)(wei)、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)首(shou)頁(ye)(ye)(ye)編碼以(yi)(yi)(yi)(yi)(yi)及(ji)(ji)(ji)(ji)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)回(hui)(hui)(hui)收(shou)(shou)(shou)等(deng)(deng)(deng)各(ge)(ge)(ge)(ge)崗(gang)(gang)位(wei)(wei)(wei)的(de)(de)(de)(de)(de)(de)(de)(de)崗(gang)(gang)位(wei)(wei)(wei)職(zhi)(zhi)(zhi)責，界定(ding)了(le)(le)任職(zhi)(zhi)(zhi)資(zi)格與(yu)(yu)(yu)(yu)(yu)崗(gang)(gang)位(wei)(wei)(wei)質(zhi)(zhi)(zhi)量(liang)指標等(deng)(deng)(deng)，將(jiang)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)職(zhi)(zhi)(zhi)責細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)至人(ren)(ren)，從(cong)(cong)(cong)而(er)(er)確(que)(que)(que)保了(le)(le)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)過(guo)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)中(zhong)有跡可(ke)循，病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)有蹤可(ke)循，各(ge)(ge)(ge)(ge)崗(gang)(gang)位(wei)(wei)(wei)之間相互監(jian)督(du)、環環相扣、責任明(ming)(ming)(ming)確(que)(que)(que)，為(wei)(wei)(wei)(wei)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)高(gao)質(zhi)(zhi)(zhi)量(liang)、高(gao)效(xiao)率(lv)完成(cheng)(cheng)提(ti)(ti)(ti)(ti)供(gong)了(le)(le)保障[4]。1.2.3對(dui)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)予(yu)(yu)以(yi)(yi)(yi)(yi)(yi)規(gui)范細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)。病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)(xi)精(jing)(jing)(jing)(jing)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)過(guo)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)中(zhong)，采用了(le)(le)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)化(hua)(hua)(hua)(hua)的(de)(de)(de)(de)(de)(de)(de)(de)規(gui)范管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)以(yi)(yi)(yi)(yi)(yi)確(que)(que)(que)保管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)責任明(ming)(ming)(ming)確(que)(que)(que)、具體，從(cong)(cong)(cong)而(er)(er)充(chong)分(fen)(fen)(fen)發(fa)(fa)揮(hui)出(chu)(chu)(chu)(chu)人(ren)(ren)力(li)資(zi)源的(de)(de)(de)(de)(de)(de)(de)(de)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)用，提(ti)(ti)(ti)(ti)高(gao)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)效(xiao)率(lv)。對(dui)此病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)科(ke)(ke)(ke)(ke)(ke)對(dui)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)予(yu)(yu)以(yi)(yi)(yi)(yi)(yi)梳(shu)理(li)(li)(li)(li)(li)分(fen)(fen)(fen)析與(yu)(yu)(yu)(yu)(yu)集體探討(tao)，以(yi)(yi)(yi)(yi)(yi)醫(yi)院(yuan)(yuan)的(de)(de)(de)(de)(de)(de)(de)(de)信(xin)息(xi)(xi)(xi)(xi)化(hua)(hua)(hua)(hua)平臺為(wei)(wei)(wei)(wei)支撐，對(dui)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)予(yu)(yu)以(yi)(yi)(yi)(yi)(yi)簡(jian)化(hua)(hua)(hua)(hua)，優化(hua)(hua)(hua)(hua)了(le)(le)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)環節(jie)(jie)之間的(de)(de)(de)(de)(de)(de)(de)(de)銜(xian)接，從(cong)(cong)(cong)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)借(jie)(jie)閱(yue)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、信(xin)息(xi)(xi)(xi)(xi)上報審(shen)核(he)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、信(xin)息(xi)(xi)(xi)(xi)變更流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)復印流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、封存啟封流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)首(shou)頁(ye)(ye)(ye)上報流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、歸(gui)檔(dang)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、ICD-10編碼擴展(zhan)(zhan)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、錄(lu)入(ru)信(xin)息(xi)(xi)(xi)(xi)審(shen)核(he)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)首(shou)頁(ye)(ye)(ye)編碼流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、交接流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)回(hui)(hui)(hui)收(shou)(shou)(shou)流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)等(deng)(deng)(deng)各(ge)(ge)(ge)(ge)個(ge)環節(jie)(jie)出(chu)(chu)(chu)(chu)發(fa)(fa)，采用流(liu)(liu)(liu)(liu)(liu)程(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)(cheng)圖將(jiang)環節(jie)(jie)與(yu)(yu)(yu)(yu)(yu)環節(jie)(jie)之間的(de)(de)(de)(de)(de)(de)(de)(de)銜(xian)接等(deng)(deng)(deng)明(ming)(ming)(ming)確(que)(que)(que)表(biao)示出(chu)(chu)(chu)(chu)來，從(cong)(cong)(cong)而(er)(er)確(que)(que)(que)保工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)人(ren)(ren)員(yuan)(yuan)得以(yi)(yi)(yi)(yi)(yi)明(ming)(ming)(ming)確(que)(que)(que)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)優先(xian)次序、工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)環節(jie)(jie)以(yi)(yi)(yi)(yi)(yi)及(ji)(ji)(ji)(ji)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)要(yao)(yao)點(dian)(dian)，為(wei)(wei)(wei)(wei)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)信(xin)息(xi)(xi)(xi)(xi)精(jing)(jing)(jing)(jing)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)創造(zao)了(le)(le)良好的(de)(de)(de)(de)(de)(de)(de)(de)條件[5]。1.2.4加(jia)大培(pei)(pei)(pei)訓力(li)度(du)。通(tong)(tong)(tong)過(guo)培(pei)(pei)(pei)訓轉變工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)人(ren)(ren)員(yuan)(yuan)的(de)(de)(de)(de)(de)(de)(de)(de)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)理(li)(li)(li)(li)(li)念，充(chong)分(fen)(fen)(fen)利用業(ye)(ye)務(wu)學(xue)(xue)(xue)習(xi)、科(ke)(ke)(ke)(ke)(ke)室周會(hui)以(yi)(yi)(yi)(yi)(yi)及(ji)(ji)(ji)(ji)晨(chen)會(hui)等(deng)(deng)(deng)學(xue)(xue)(xue)習(xi)機(ji)會(hui)，組(zu)織科(ke)(ke)(ke)(ke)(ke)內(nei)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)人(ren)(ren)員(yuan)(yuan)學(xue)(xue)(xue)習(xi)精(jing)(jing)(jing)(jing)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)理(li)(li)(li)(li)(li)論，使其對(dui)當前(qian)(qian)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)科(ke)(ke)(ke)(ke)(ke)內(nei)存在的(de)(de)(de)(de)(de)(de)(de)(de)問題做(zuo)出(chu)(chu)(chu)(chu)全面的(de)(de)(de)(de)(de)(de)(de)(de)了(le)(le)解(jie)，意識(shi)到(dao)進(jin)行(xing)(xing)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)精(jing)(jing)(jing)(jing)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)的(de)(de)(de)(de)(de)(de)(de)(de)必(bi)要(yao)(yao)性(xing)(xing)，通(tong)(tong)(tong)過(guo)培(pei)(pei)(pei)訓調動人(ren)(ren)員(yuan)(yuan)的(de)(de)(de)(de)(de)(de)(de)(de)能(neng)(neng)動性(xing)(xing)、創造(zao)性(xing)(xing)以(yi)(yi)(yi)(yi)(yi)及(ji)(ji)(ji)(ji)積極性(xing)(xing)。通(tong)(tong)(tong)過(guo)培(pei)(pei)(pei)訓促使工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)人(ren)(ren)員(yuan)(yuan)意識(shi)到(dao)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)科(ke)(ke)(ke)(ke)(ke)提(ti)(ti)(ti)(ti)供(gong)的(de)(de)(de)(de)(de)(de)(de)(de)服務(wu)應以(yi)(yi)(yi)(yi)(yi)滿(man)足病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)服務(wu)需(xu)求(qiu)、提(ti)(ti)(ti)(ti)高(gao)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)質(zhi)(zhi)(zhi)量(liang)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)為(wei)(wei)(wei)(wei)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)重點(dian)(dian)，進(jin)而(er)(er)提(ti)(ti)(ti)(ti)高(gao)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)量(liang)與(yu)(yu)(yu)(yu)(yu)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)效(xiao)率(lv)，充(chong)分(fen)(fen)(fen)發(fa)(fa)揮(hui)出(chu)(chu)(chu)(chu)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)的(de)(de)(de)(de)(de)(de)(de)(de)信(xin)息(xi)(xi)(xi)(xi)價(jia)(jia)值。1.2.5加(jia)大考(kao)(kao)核(he)力(li)度(du)。嚴格執(zhi)行(xing)(xing)考(kao)(kao)核(he)能(neng)(neng)為(wei)(wei)(wei)(wei)各(ge)(ge)(ge)(ge)項工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)得以(yi)(yi)(yi)(yi)(yi)持續(xu)開展(zhan)(zhan)與(yu)(yu)(yu)(yu)(yu)貫徹(che)落(luo)實(shi)(shi)(shi)提(ti)(ti)(ti)(ti)供(gong)保障，病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)科(ke)(ke)(ke)(ke)(ke)堅持可(ke)操(cao)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)、簡(jian)便的(de)(de)(de)(de)(de)(de)(de)(de)原則建(jian)(jian)立(li)了(le)(le)各(ge)(ge)(ge)(ge)崗(gang)(gang)位(wei)(wei)(wei)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)時(shi)效(xiao)、工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)質(zhi)(zhi)(zhi)量(liang)的(de)(de)(de)(de)(de)(de)(de)(de)考(kao)(kao)核(he)標準(zhun)與(yu)(yu)(yu)(yu)(yu)考(kao)(kao)核(he)指標，為(wei)(wei)(wei)(wei)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)人(ren)(ren)員(yuan)(yuan)進(jin)行(xing)(xing)考(kao)(kao)核(he)與(yu)(yu)(yu)(yu)(yu)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)人(ren)(ren)員(yuan)(yuan)明(ming)(ming)(ming)確(que)(que)(que)考(kao)(kao)核(he)標準(zhun)、明(ming)(ming)(ming)確(que)(que)(que)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)方(fang)向提(ti)(ti)(ti)(ti)供(gong)了(le)(le)便利[6]。將(jiang)考(kao)(kao)核(he)結(jie)(jie)果與(yu)(yu)(yu)(yu)(yu)培(pei)(pei)(pei)訓進(jin)修機(ji)會(hui)、年(nian)終評優、個(ge)人(ren)(ren)績效(xiao)等(deng)(deng)(deng)掛(gua)鉤(gou)(gou)，從(cong)(cong)(cong)而(er)(er)充(chong)分(fen)(fen)(fen)激發(fa)(fa)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)人(ren)(ren)員(yuan)(yuan)的(de)(de)(de)(de)(de)(de)(de)(de)工(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)作(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)(zuo)積極性(xing)(xing)與(yu)(yu)(yu)(yu)(yu)學(xue)(xue)(xue)習(xi)積極性(xing)(xing)，通(tong)(tong)(tong)過(guo)不(bu)斷學(xue)(xue)(xue)習(xi)以(yi)(yi)(yi)(yi)(yi)發(fa)(fa)揮(hui)自身潛能(neng)(neng)，提(ti)(ti)(ti)(ti)高(gao)自身的(de)(de)(de)(de)(de)(de)(de)(de)綜合業(ye)(ye)務(wu)素質(zhi)(zhi)(zhi)。以(yi)(yi)(yi)(yi)(yi)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)回(hui)(hui)(hui)收(shou)(shou)(shou)制(zhi)(zhi)度(du)為(wei)(wei)(wei)(wei)例(li)，病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)科(ke)(ke)(ke)(ke)(ke)出(chu)(chu)(chu)(chu)臺病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)回(hui)(hui)(hui)收(shou)(shou)(shou)制(zhi)(zhi)度(du)，其中(zhong)明(ming)(ming)(ming)確(que)(que)(que)規(gui)定(ding)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)回(hui)(hui)(hui)收(shou)(shou)(shou)率(lv)與(yu)(yu)(yu)(yu)(yu)回(hui)(hui)(hui)收(shou)(shou)(shou)人(ren)(ren)員(yuan)(yuan)的(de)(de)(de)(de)(de)(de)(de)(de)獎(jiang)金掛(gua)鉤(gou)(gou)，病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)超時(shi)送交與(yu)(yu)(yu)(yu)(yu)醫(yi)師獎(jiang)金掛(gua)鉤(gou)(gou)，通(tong)(tong)(tong)過(guo)定(ding)期考(kao)(kao)核(he)與(yu)(yu)(yu)(yu)(yu)反饋考(kao)(kao)核(he)結(jie)(jie)果，醫(yi)師與(yu)(yu)(yu)(yu)(yu)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)回(hui)(hui)(hui)收(shou)(shou)(shou)人(ren)(ren)員(yuan)(yuan)均對(dui)此高(gao)度(du)重視(shi)，病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)長期滯(zhi)留于(yu)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)房等(deng)(deng)(deng)現象(xiang)(xiang)顯著減少，病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)回(hui)(hui)(hui)收(shou)(shou)(shou)率(lv)上升。1.3觀察(cha)(cha)指標。觀察(cha)(cha)精(jing)(jing)(jing)(jing)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)實(shi)(shi)(shi)施前(qian)(qian)后(hou)的(de)(de)(de)(de)(de)(de)(de)(de)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)情(qing)(qing)況(kuang)(kuang)(kuang)(kuang)，病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)情(qing)(qing)況(kuang)(kuang)(kuang)(kuang)包(bao)(bao)括(kuo)(kuo)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)歸(gui)檔(dang)正確(que)(que)(que)率(lv)、ICD編碼正確(que)(que)(que)率(lv)、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)首(shou)頁(ye)(ye)(ye)合格率(lv)、病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)3日(ri)回(hui)(hui)(hui)收(shou)(shou)(shou)率(lv)等(deng)(deng)(deng)，選(xuan)取實(shi)(shi)(shi)施前(qian)(qian)后(hou)的(de)(de)(de)(de)(de)(de)(de)(de)15,000份(fen)(fen)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)的(de)(de)(de)(de)(de)(de)(de)(de)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)情(qing)(qing)況(kuang)(kuang)(kuang)(kuang)進(jin)行(xing)(xing)評價(jia)(jia)；觀察(cha)(cha)實(shi)(shi)(shi)施精(jing)(jing)(jing)(jing)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)前(qian)(qian)后(hou)的(de)(de)(de)(de)(de)(de)(de)(de)10,000份(fen)(fen)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)復印服務(wu)的(de)(de)(de)(de)(de)(de)(de)(de)投(tou)訴情(qing)(qing)況(kuang)(kuang)(kuang)(kuang)，通(tong)(tong)(tong)過(guo)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)服務(wu)投(tou)訴率(lv)進(jin)行(xing)(xing)評價(jia)(jia)；觀察(cha)(cha)實(shi)(shi)(shi)施精(jing)(jing)(jing)(jing)細(xi)(xi)(xi)化(hua)(hua)(hua)(hua)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)前(qian)(qian)后(hou)的(de)(de)(de)(de)(de)(de)(de)(de)3,000份(fen)(fen)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)借(jie)(jie)閱(yue)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)理(li)(li)(li)(li)(li)情(qing)(qing)況(kuang)(kuang)(kuang)(kuang)，從(cong)(cong)(cong)借(jie)(jie)閱(yue)病(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)(bing)案(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)(an)按(an)時(shi)歸(gui)還率(lv)方(fang)面進(jin)行(xing)(xing)評價(jia)(jia)。1.4統計(ji)學(xue)(xue)(xue)處理(li)(li)(li)(li)(li)。數(shu)據經SPSS19.0處理(li)(li)(li)(li)(li)，計(ji)量(liang)資(zi)料(liao)行(xing)(xing)t檢驗，計(ji)數(shu)資(zi)料(liao)行(xing)(xing)卡方(fang)檢驗，P<0.05為(wei)(wei)(wei)(wei)差異有統計(ji)學(xue)(xue)(xue)意義。

2結果