The quarterly work plan of medical record room Medical record management is a marginal subject with its own theories and laws. Establishing and perfecting various rules and regulations of medical record management, clarifying the post responsibilities of department personnel, strengthening the professional ethics of department personnel, constantly improving their own quality, and managing medical records by standardized, standardized and modern means will certainly open up a new situation.
First, standardized and transparent medical record management.
Establish a manual of rules and regulations for medical record management, and post public signs on the wall, such as medical record borrowing system, medical record borrowing process, medical record copying system, medical record copying workflow, medical record management workflow, medical record room job responsibilities, medical record safety management system, etc., for the convenience of doctors who borrow medical records and visitors who request to copy medical records.
Understand and cooperate with medical record management, which is also convenient for staff to refer to in their daily work.
Second, improve work design and responsibility management.
It is an important premise to ensure the orderly work and an important content of standardized management to establish a job description and clarify the job responsibilities of the medical record department. Irregular and vague responsibilities seriously restrict the improvement of work efficiency and the full play of employees' potential. According to the actual work position of the department, taking into account the individual's work ability, the tasks, responsibilities and powers of each position and the relationship with other positions are stipulated.
Third, do a good job of medical record recycling, borrowing and shelving.
Whether the medical records are collected in time, put on shelves in time and accurately entered into the home page directly affects the inquiry and copying of medical records, so the system of collection, borrowing and filing must be strictly implemented. Insist on checking the recovered medical records and ward logs every day, and check the discharged medical records every month, quarter and year.
Filing situation, check and supervise the borrowing of unreturned medical records, inquire about the whereabouts of unreturned medical records in clinical departments, report the filing and management of medical records to superiors in writing, and ensure that medical records are not leaked or lost and filed on shelves in time.
Fourth, strengthen the quality management of electronic medical records.
With the gradual implementation of Regulations on Handling Medical Accidents, Tort Liability Law and Guangdong Medical Records Writing Standard, people's legal awareness has been continuously strengthened, and the quality of medical records is related to the "life and death" of hospitals. Starting from next year, our hospital will implement all electronic medical records. Judging from the quality of medical records in various pilot departments, the quality monitoring and management of electronic medical records in our hospital is very serious. We can make full use of the digital characteristics of electronic medical records, introduce electronic medical record quality monitoring software, and monitor the dynamic process of various quality monitoring indicators according to the requirements of the work plan, work plan format, work plan, work plan, monthly work plan and quarterly work plan of Shaanxi Medical Record Writing Specification, and automatically record whether the content, time and quality of each medical record writing item meet the requirements, and score them. More importantly, the software system automatically prompts the medical staff according to the dynamic monitoring results, so that the medical staff can improve in time and improve the writing quality of medical records and medical quality; Hospital leaders, medical quality management departments, department directors and medical staff can view and track medical records and medical quality problems in time through software systems, and carry out real-time dynamic management to achieve management effects that traditional manual management cannot achieve.
Fifth, improve the effective use of medical record information.
On the basis of standardizing medical records and information collection, the information related to the retrieval subject in the database of medical record management system can be arranged logically according to the needs of users. Orderly integration provides the required high solubility information. Carry out medical record information services such as thematic retrieval, comprehensive inquiry and data statistical analysis. Improve the service effect and establish a flexible
Search mode, establish search points from multiple angles, improve recall and precision, and try to meet their individual needs. For example, it provides information and data for the training of various scientific research topics and teaching practice for undergraduates and junior college students, and provides good services for them to write papers. Integrate, quickly, accurately and pertinently provide diversified medical records to help doctors reduce blind retrieval and save consultation time.
Six, strengthen the safety management of medical record database.
Strengthen the management of medical record warehouse, keep the warehouse clean and ventilated, and do a good job in sun protection, corrosion prevention, insect prevention, theft prevention and fire prevention.
Seven, do a good job in health statistics.
In strict accordance with the reporting system of the health department, complete the required reports accurately, timely and comprehensively, establish the feedback information system of functional departments and clinical departments, and compile the annual statistical data, which is rich in content, focused, contrasted and analyzed, and expressed by words, tables and graphics. It is necessary to improve the statistical ledger, including the list of hospitalized dead patients, the list of hospitalized critically ill patients and the list of hospitalized surgical patients.
Eight, do a good job of direct reporting of death certificates.
According to the implementation plan of death case monitoring in medical institutions at or above the county level (for Trial Implementation), we should conscientiously do a good job in reporting the death certificate. Carry out training courses on filling out death certificates, and strive to improve the accuracy and completeness of doctors filling out death certificates. In strict accordance with the requirements of ICD- 10 (tenth edition of the International Classification of Diseases), the cause of death was uniformly coded, and the network direct reporting work was completed within 7 days.
Nine, do a good job to meet the hospital grade re-evaluation.
It is inevitable that all provincial hospitals of traditional Chinese medicine will participate in grade evaluation this year.
The evaluation methods of medical record management in hospital grade evaluation include: consulting materials, reviewing medical records, practical operation evaluation, on-site question and answer, etc. Therefore, it needs the joint efforts of general practitioners, and carefully refers to the standards and rules of hospital grade evaluation to do a good job in hospital evaluation in advance.
Ten, strengthen and change the enthusiasm and attitude of employees.
The value of medical record work is realized through service. With the continuous expansion of the scope of medical records, they are used more and more, not only for medical workers, but also for all walks of life. Since the implementation of the Regulations on Handling Medical Accidents, the medical record room has become an important service window of the hospital, which reflects the service image of the hospital from another aspect. Medical record managers should constantly improve their professional level and personal quality, have lofty professional ethics and change their work enthusiasm and attitude. No matter what kind of customers they are, they should be greeted with smiles. We should be objective and true in words and actions, and we should not judge at will. We should be responsible for patients, ourselves and hospitals.
Eleven, strengthen personnel training, improve the overall quality of medical record personnel.
The quality and professional level of medical record managers will directly affect medical record management, so to do a good job in medical record management, we must establish a high-level and high-quality medical record management team. First of all, we should strengthen professional ethics education, establish a people-oriented humanistic concept, enhance service awareness, and strive to improve service quality. Secondly, the training of related disciplines, medical record management involves basic medicine, clinical medicine, management, medical statistics, medical record science, computer, laws and regulations and other disciplines, requiring staff to have a diversified knowledge structure to meet the new needs of modern medical record management. Encourage everyone to actively participate in knowledge lectures inside and outside the hospital, strengthen business exchanges, and improve the overall quality of the medical record management team as soon as possible.