Personal work summary of medical record management 1
From 20 years to 2000, with the strong support of hospital leaders and the cooperation of clinical departments, the actual work of medical record management Committee has achieved certain results. The work this year is summarized as follows:
1. This year, on the basis of organizing all medical staff to learn the Guangdong Medical Record Writing and Management Standard issued by the Guangdong Provincial Health Department, our hospital formulated the Detailed Rules for Rewards and Punishment of Inpatient Medical Record Writing in May, which set clear requirements for problems that are difficult to correct in clinical medical record writing, and formulated reward and punishment measures, which mainly inspired the enthusiasm of medical staff, made the quality of medical records go up a step, and the number of Class B medical records was significantly higher than that of the previous year.
2. In view of the widespread phenomenon of delayed filing of medical records, this year we still strengthened the monitoring of medical records recovery, and the responsibility lies with people, and the medical records are checked every month. According to the hospital management rules of our hospital, the person responsible for the delay was severely punished, which significantly shortened the time for timely recovery of discharged medical records.
3. This year, the quality control management of outpatient emergency medical records was strengthened. The Medical Record Management Committee clearly put forward the writing norms and informing principles of emergency medical records, requiring drivers and nurses to cooperate with each other to complete the standardized writing of pre-hospital emergency medical records and the signing of informed consent, and regularly sort out and file the medical records of each pre-hospital emergency patient, so as to eliminate medical safety hazards from the first visit.
4. Strengthened the implementation of informed consent, informed notification and informed choice system, focusing on the implementation of surgical safety verification system, effectively improving patient satisfaction and medical record quality, reducing medical risks and ensuring medical safety.
5. Strengthen the quality management of outpatient medical records. The quality control department conducts a spot check on outpatient medical records every quarter, and urges the rectification of existing problems in the form of roll call notice, which effectively improves the writing quality of outpatient medical records.
6, strengthen the supervision of the implementation of quality control work in various departments, departments should hold a meeting of medical record management quality control personnel once a month as required, and hospitals should hold a meeting once a quarter, so that the medical record writing problems found in department-level and college-level quality control can be timely feedback and rectified; At the same time, the accountability system of medical record quality management was implemented, and the doctors in charge, quality control doctors and department heads of Class B and C medical records were punished according to the hospital management rules of our hospital, which effectively improved the quality of medical record writing.
Summary of personal work in medical record management II
Medical record information is one of the important departments of the hospital and plays an important role in the information work of the whole hospital. Since its opening, with the strong support of hospital leaders, the medical record room has clarified its thinking, defined its tasks, adhered to the guiding ideology of information work serving the scientific management of the hospital, closely focused on the development and construction of the hospital, fully performed its duties, highlighted the key points of comprehensive information work serving the hospital management and clinical frontline, successfully completed various tasks since its opening, and promoted the development and smooth operation of hospital information construction. The work of the medical record room in 2000 is summarized as follows:
First, the construction and preparation of medical record room.
One month before the opening, the staff of our hospital's medical record room actively arrived at their posts and devoted themselves to the construction and preparation of our hospital's medical record room.
(a) the medical record room warehouse renovation and construction work.
(1) The available space of two warehouses in the original medical record room is about 48.9m2 and 24.7m2 respectively. In order to increase the reserved space for storing medical records, a relatively small warehouse in the medical record room was switched with a reading room with a size of about 46.2㎡.
(2) Due to the adjustment of the medical record room warehouse, the office space is reduced, so the medical record room warehouse is expanded by about 1 1.3m2 for reception, inquiry and copying.
(2) Infrastructure preparation of medical record room.
(1) The medical record room is quite special, and it needs good facilities such as fire prevention, moisture prevention, moisture prevention and moth prevention. Reduce the harm of unfavorable factors to the medical record carrier. The lighting system of the medical record room in our hospital is uniformly adjusted to explosion-proof lights, and fire-proof security doors and password electronic access control systems are installed. At the same time, we also purchased medical records disinfection cabinet, air disinfection machine, dehumidifier and other equipment.
(2) Considering the low utilization rate of warehouse space, the use of dense cabinets wastes resources, and the medical record storage space reserved for five years can not reach, we use iron shelves to store medical records.
(3) Actively communicate with clinical departments.
In order to carry out the work of medical record room smoothly, in the early stage of opening, the staff of our department visited various clinical departments, educated them on the rules and regulations and matters needing attention in the medical record room of Southern Hospital of our hospital, and listened to the opinions of various clinical departments.
Two, improve the management level of medical record room, and further improve the rules and regulations.
The procedure of medical record management is the key point of medical record management, and the borrowing, entry and quality inspection of medical records are carried out in accordance with the corresponding system. As a new hospital, Southern Hospital has higher requirements in its work, and the system of its undergraduate department has been improved.
(1) Provisions on the filing management of discharged medical records. Sign the discharge medical record twice a week.
(2) The borrowing system of archived medical records. Southern Hospital of our hospital strictly implements the lending system of "only in and out" of archived medical records, puts an end to lending medical records and ensures that medical records can only be consulted in the medical record room.
Third, do a good job in the functional services of the department.
General practitioners obey the arrangement of the hospital, pay attention to their own work, and Qi Xin works together to complete all the work.
(1) medical record preservation.
The storage and preservation of medical records is an important work in medical record management, and medical record warehouse is the key link of medical record protection. Due to the limited conditions in our hospital and the shortage of medical record warehouse, under the existing conditions, the warehouse can be kept clean and dry, and it can be fire-proof, heat-proof, moisture-proof, insect-proof and mildew-proof. The recovered medical records can be disinfected, sorted, bound, entered, filed, color-coded and put on the shelves in time to ensure the integrity of each medical record without mistakes and omissions.
According to the International Classification and Coding of Diseases (ICD- 10) and Surgical Classification (ICD-9-cm-3), each discharged medical record was classified and coded. By the end of 20-2006120, 165438+ the medical record room had completed the work of signing, sorting, quality inspection, coding, filing and color coding of 6,304 medical records.
(2) Final quality inspection of medical records.
We check the medical records as comprehensively as possible. If any problem is found in each medical record, inform the doctor to revise it in the medical record room in time. Communicate with doctors in time for major problems and remind them to correct them in the future. Put an end to modifying medical records after filing, and don't give doctors the illusion that they can modify medical records and rely on the medical record room. At the same time, supervise clinicians to correct the writing problems such as the first page of medical records, discharge summary and admission records in accordance with the writing standards.
(3) Borrowing and copying.
Borrowing and copying are the window posts in our department. The employees in our department can do this job dutifully in accordance with laws and regulations, without losing flexibility, and are well received by the employees. In the process of copying patients, strictly implement the system, flexibly grasp the principles, avoid disputes with patients as much as possible, and do a good job in hospital medical services for patients.
(4) About sentences.
Regularly report the filing rate and defect rate of discharged medical records every week. Summarize and monitor the monthly filing of discharged medical records, effectively improve the filing rate of discharged medical records, and the monthly filing rate of discharged medical records is about 97.97%. Strictly review the statistical data in the report, change the wrong and untrue figures in time, and be true, accurate and well-founded.
Fourth, the breakthrough and achievements in the work of medical record room.
The Southern Hospital of our hospital has inherited the rules and regulations and management methods of our department, played its advantages and achieved good results.
(1) The filing system within 7 days.
It ensures the timeliness of medical record filing, improves the phenomenon of delayed filing of medical records, facilitates the timely statistics and effective utilization of medical record information, greatly improves the filing rate of medical records, and reaches the latest Detailed Rules for the Implementation of Evaluation Standards for Tertiary General Hospitals.
(2) File medical records with color coding.
Our department marks each medical record with its own unique color-coded filing method. Put an end to the wrong frame of medical records, and facilitate the identification and rapid extraction of medical records.
(3) The "closed" borrowing system of medical records.
Avoid the circulation of medical records and ensure that medical records are not lost.
(4) beyond the scope of responsibilities, make full use of time to control the quality of medical records.
The contents of quality control inspection include whether the information on the first page of medical records is accurate and complete; Whether there is a lack of various medical documents; Whether the signature of the medical document is missing; Check whether other people's reports are wrong; Check whether the report is forged; And check whether the revision of various medical documents conforms to the medical record writing standard.
(5) Standardize the examination and approval process for recall and modification of archived medical records.
The medical record room receives the application form for medical record recall and modification, and timely communicates whether the medical record has been copied. If the medical record has been copied by the patient, refuse to let the clinician modify it.
(6) Disinfection and preservation of medical records.
Our department immediately used the document disinfection cabinet for ozone disinfection and sterilization after medical record recovery, and air disinfection machine was used for disinfection and sterilization in the medical record room on the same day. Air disinfection machine disinfection and dehumidifier dehumidification are carried out on the medical record warehouse regularly every month to protect the medical record from mildew and moth.
Five, the results of business learning.
None of the staff in our medical record room graduated from medical record major, but we all actively participated in learning and training opportunities to improve our professional level. In June 2000, the department participated in the 1 1 academic exchange meeting on hospital medical record information management. At the same time, the academic papers "Problems in Information Quality Management of the First Page of Medical Records" and "Experience in Talking about Injury Coding" were invited and exchanged at the meeting.
The medical record room is a comprehensive, coordinated and neutral service work, which should have a strong sense of professionalism, a high sense of responsibility and a pragmatic working attitude. In the future work, the department will continue to learn and apply advanced digital management methods of medical record data, and strive to develop new businesses and technologies to make greater contributions to hospital medical record management. Finally, we plan to improve the following aspects in 2008:
1. At present, our hospital adopts serial number. This method of dividing patients' medical information is not conducive to patients seeking medical treatment, resulting in a waste of manpower and material resources, and it is difficult to provide patients with complete medical information. Whether it is possible to distinguish the hospitalization numbers of outpatients and inpatients for 20 years, so as to ensure that the hospitalization records can be numbered continuously and facilitate the management of the medical record room.
2. Can you provide patients with telephone booking service to read and copy medical records, reduce the waiting time of patients, and avoid complaints to doctors when patients go back and forth to the hospital to apply for copying medical records because they are not filed?
3. The medical record room is located in the basement, often facing the situation of pipeline leakage. The construction of medical record room warehouse urgently needs hospital inspection, and a suitable location is arranged to ensure that medical records can be moisture-proof and waterproof.
4. Improve the business level. The personnel engaged in medical record management come from other majors, and there is a shortage of professionals in this major or related majors, so we need to strengthen our business study and continuously improve our professional level. Can you provide more training and learning opportunities, study DRGs, and take the qualification certificate of coders?
Summary of personal work in medical record management III
June 6, 2008, I came to work in the people's court. At the beginning, for me without any work experience, faced with such a job, my mood was complicated and my heart was under great pressure. But I think this is also experienced and honed for a fledgling graduate like me, so I embarked on this unforgettable journey with confidence.
In practical work, through unremitting efforts, the concern of leaders and the enthusiastic help of colleagues, I gradually integrated into the big family of People's Hospital. Here I learned the truth of being a man and how to deal with people. I strictly abide by the rules and regulations of the hospital, earnestly perform my duties as an intern nurse, be strict with myself, never arrive late and leave early without reason, work steadily, and actively participate in various activities organized by the hospital on time.
The medical record room is a comprehensive work, a work of coordination and service. An excellent medical staff in the medical record room should not only have a strong sense of professionalism, a high sense of responsibility and a pragmatic work attitude, but also have excellent political quality and technical level, rigorous and meticulous work style and hard-working dedication. But I always believe that as long as I work hard and take every task seriously, I will be recognized by leaders, colleagues and patients.
My first task when I entered the hospital was to get familiar with the working environment, learn the computer case input system, cooperate with the leaders to copy and distribute the information of various departments in time, and notify the unfinished cases in time. I always practice "serving leaders, departments and patients well".
Summary of personal work in medical record management 4
The medical record room is a comprehensive, coordinated and neutral service. A qualified medical record room staff has strong professionalism, high sense of responsibility and pragmatic working attitude, strong political quality and professional ability, rigorous and capable work style and hard-working spirit. I always believe that as long as I work hard and take it seriously, I will be recognized.
When I entered the hospital, my important task was to be familiar with the working environment, learn the computer case input system, cooperate with the leaders to copy and distribute the information of various departments in time, and notify the unfinished cases in time. I always practice the working concept of "serving the leaders, departments and patients well", conscientiously complete all the work arranged by the leaders, cooperate with the leaders to successfully complete the work tasks, cultivate comprehensive quality and improve work ability. Don't let the work arranged by the leaders be delayed in your own hands, don't let the matters handled accumulate in your own hands, don't let all kinds of mistakes happen to you, and don't let the patients who copy medical records be left out in the cold here, so as to cultivate service consciousness. Accurately understand the important role of medical record management, enhance the understanding of the modernization of medical record management, and report the medical records encountered in litigation to the leaders in time.
Always keep a clear political mind, put yourself in a correct position, and try to arrange your work in an orderly way. It is in this mood that I study hard, "I am safe when I come." Put the enthusiasm for the cause and a highly serious and responsible attitude into the work, resolutely obey the leadership and serve the patients. Consciously abide by the rules and regulations of the hospital and labor discipline, and meet the needs of patients to the maximum extent.
I like and cherish this position very much. It is not only a melting pot, but also a stage, which can not only exercise itself, but also show itself in 20 years of secretary's debriefing. Looking back on my work during this period, I have basically completed my job, which is inseparable from the support of my leaders and the help of my colleagues. I would like to express my heartfelt thanks to all the leaders and colleagues!
The above is my summary of my future thoughts and work. Please criticize and correct those that are incomplete and inaccurate. In my future work, I will make a personal work plan to make my work better. Live up to the expectations of the leaders.
Personal medical record management work summary 5 pages
From 20 to 2000, with the care and training of leaders and the help of colleagues, I constantly strengthened my business study, improved my work, worked together with the employees of the department, and successfully completed all the work, and my personal business ability also improved to some extent. The work and study are summarized as follows:
First, ideologically:
Love the motherland, love China * * * production party, love their jobs; Consciously safeguard the reunification of the motherland, safeguard national unity, oppose national division, and take a clear-cut stand against the "three forces"; Love your post and do your duty. Finish the work assigned by the leader in time, handle the relationship with the staff of all departments in the hospital, pay attention to your words and deeds, be kind to others, be honest and open-minded; Keep a normal mind at work, properly handle people and things, especially be patient with patients and their families, know the needs of patients and their families in time, and help those in need as much as possible; Seriously study laws and regulations, so as to know, understand and abide by the law, seriously study the party's mass line education practice activities, criticize and self-criticize in the activities, and humbly accept and correct the opinions put forward by comrades to me; Pay attention to safety work at all times when on duty, constantly urge emergency and outpatient safety personnel to do a good job of registration and inspection, patrol departments irregularly, and solve problems in time when found.
Second, at work:
In a positive, serious and responsible working attitude, I will earnestly abide by various rules and regulations, obey the arrangement of hospitals and departments, keep the office environment clean and tidy, and do a good job in fire prevention and theft prevention. I am not afraid of hardship and fatigue in my work, which makes my work rigorous and meticulous. Since I transferred to the medical record room, I have carefully studied the post responsibilities, rules and regulations, coding and statistical knowledge of the medical record room, and humbly asked the leaders and predecessors for advice. As the saying goes, when I first arrived in the medical record room, I had to learn everything from scratch, so I used my spare time to constantly recharge myself, read professional books, join QQ groups related to medical records, and learn coding related knowledge from my predecessors. When I got the opportunity to study abroad in the hospital, I cherished every learning opportunity, observed classroom discipline, made good class notes, sorted out the problems and puzzles encountered in my work in advance, and asked the teacher for advice in time, thus establishing a good friendship between teachers and students, which provided great help for my future work. Through studying abroad, I brought the comprehensive diagnostic coding technology from other hospitals back to our hospital, which improved the coding accuracy. Since taking over the statistical report in July, with the help and cooperation of the brother departments, the monthly report, quarterly report and online direct report have been completed on time. Through continuous learning and accumulation, the work efficiency and quality have been greatly improved, and various tasks have been successfully completed.
Third, the attendance rate:
Strictly abide by the attendance system, attend all kinds of studies, meetings and exams in hospitals and departments on time, so as not to be late, not to leave early, not to be off duty or to be on duty all year round, without sick leave or personal leave, and have four days' annual leave due to work needs.
Four. Achievements:
Learn coding work and obtain corresponding qualifications at the autonomous region level, and learn medical record statistics. I can independently complete monthly reports, quarterly reports and online direct reports, and I can issue reports on time, and I have completed 365,438+0 points for continuing education credits.
Of course, I still have many shortcomings in many aspects, not considerate enough and not meticulous enough. Now I have realized my own problems through summing up, and I am determined to improve and solve them in my future work, complete the tasks assigned by the leaders in time, improve my own quality, set goals for myself in my future work and life, and work hard towards my customized goals.
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