The construction of key disciplines is a very important task with strategic development in the construction of general hospitals [1]. As a special discipline in the discipline team, medical record management belongs to the marginal discipline, and a large amount of data for medical development and application comes from medical record data. However, hospital medical record rooms (departments) are mostly ignored by hospitals, and the quality of talent teams is low and investment is insufficient. The level of medical record management is not optimistic, the discipline of medical record room develops slowly, and some hospital medical record rooms even shrink. With the progress and development of science and technology, hospital management is more scientific, medical research is more extensive and in-depth, and medical record information management is also advancing with the times. At the same time, it has also been deeply influenced and impacted by modernization and informatization, and has undergone major changes in concepts, technologies and methods. In the process of development, some wrong ideas lead to misunderstandings in management, which seriously hinder the normal development of the specialty, affect the hospital's investment in medical record information management, make the discipline construction and development of medical record room worse, and affect the enthusiasm of staff. How to develop the discipline of medical record management in medical record room under the new situation and improve the status and enthusiasm of medical record managers is a problem that managers must think deeply and is also the direction of medical record managers' efforts. Facing the new situation, the medical record room of our hospital has done a lot of work in the discipline construction of medical record management and achieved certain results, which are now provided for medical record managers to learn from.
1 The importance of leaders, the support of various departments and the understanding and cooperation of medical staff are the first conditions.
1. 1 Leadership's attention and support is the premise of discipline construction and development.
Without the attention and support of hospital leaders, the construction and development of medical record management discipline will become empty talk. The development of hospitals can not be separated from accurate medical record information, which can provide a large number of statistical analysis data sources for medical treatment, teaching, scientific research, epidemiology and health economics. Paying attention to the development of medical record room and medical record data, sorting out, mining and statistically analyzing the original data in medical records can provide strong data support for hospital management decision-making, improve hospital management level and make the hospital develop in an all-round way. With these ideas, hospital leaders can attach importance to the discipline construction of medical record room and give the greatest support. At the same time, according to the requirements of medical record management, the medical record management department of secondary hospitals should be directly led by the president and vice president of the hospital, and given the decision-making power and suggestion power to the academic leaders, so as to make the discipline develop rapidly. Over the years, successive leaders of our hospital have been pioneering and advancing with the times. Coupled with our multi-party publicity, hospital leaders are fully aware of the importance of medical records to hospital management and development. In 2007, the medical record room was reorganized into a hospital business department, which exercised the functions of some functional departments and was directly under the leadership of the vice president of business. The director was held by a senior professional title and approved by the Municipal Health Bureau. Hospital leaders have increased their support for the discipline construction of medical record room, increased the input of manpower and material resources, and invested millions of yuan in the development of medical record room in recent years, which has improved our medical record room in hardware and software and realized modern management.
1.2 The support of various departments is an indispensable force for the discipline construction and development.
Whether the medical record room is advanced and complete is the material guarantee for the discipline construction of medical record management. In addition to the traditional medical record rack, enhanced medical record rack, desks and chairs and other office supplies, with the application of modern technology in medical record information management, its material guarantee also includes a large number of electronic equipment such as computers, printers, barcode machines, disks, digital copiers and fax machines. These are inseparable from the support of hospital material support department, computer center and property department; The cultivation of talents in medical record room and going abroad for further study can not be separated from the support of medical departments and teaching departments; The introduction and investment of talents can not be separated from the support of personnel departments and so on. Therefore, getting the support of various departments is a force that cannot be ignored in discipline construction. As the director of the medical record room, he should constantly improve his management level, innovative consciousness and coordination ability in all aspects; Medical record managers should also do a good job in interpersonal relationships with personnel in various departments. With the attention of hospital leaders and the support of various departments, the medical record room of our hospital is currently equipped with computers, printers, bar code printers, balers, punching machines, scanning guns, copiers, compact shelves, dehumidifiers, air conditioners, thermometers, etc. In the past six years, we have enrolled 3 clinical postgraduates and 5 undergraduates. Send more than 30 people to participate in various training exchanges at home and abroad; So that the discipline construction and development of our department can be guaranteed by materials and talents.
1.3 The understanding and cooperation of medical staff are favorable conditions for the discipline construction and development.
In order to make medical staff realize the importance of medical record management, the work of medical record managers is not simply to sort and bind the archived medical records, but to carefully sort, classify, bind, enter, code, check, control the final quality and put them on the shelves according to the requirements of medical record management. The whole medical record management process is rigorous. Medical record management is as professional as clinical medicine; The quality of medical record management will affect medical quality, prevention of medical disputes, scientific research management, scientific utilization and teaching quality. Through propaganda and practical work, medical staff can understand and cooperate with medical record management, and create favorable conditions for the discipline construction and development of medical record room. We publicize the importance of medical record management through various occasions, often feedback the quality problems of medical records written by medical staff, and give rectification opinions and suggestions, so as to put an end to class C medical records, greatly reduce class B medical records, improve the first-class rate of medical records in various departments, reduce the economic losses and other penalties of clinical departments and medical staff, and ensure that their medical records pass various inspections by superiors. The development of medical record room provides all kinds of information for clinical medical staff, improves their medical treatment, scientific research and teaching level, and makes them use medical record information more quickly and conveniently. At the same time, it is supplemented by the implementation of medical record management reward and punishment system to improve its compliance with medical record management. Through the benefits brought by these practical work and the constraints of the system, medical staff can truly understand the importance of medical record management and actively cooperate with the work of medical record room, so that the discipline construction and development of medical record room can be smoother.
2. Clear discipline development plan
Discipline planning is the blueprint and foundation of discipline construction. Concise and clear, grasp the main direction of hospital disciplines, and develop superior and characteristic disciplines with unique abilities. Concise discipline direction is the key to discipline construction. It is necessary to base ourselves on local conditions, closely follow the advanced counterparts in the country, and formulate construction plans and plans in line with the development of this discipline according to the actual situation of the unit, clarify the purpose, direction and project areas of discipline construction, and formulate personnel training, scientific research and academic echelon construction. According to the current situation of medical record management in our hospital, the local city, provincial hospitals, several domestic 3A hospitals and the development level of this major, a three-year and five-year discipline development plan was formulated and gradually realized. First of all, it analyzes the current situation of our college, including the quality of talents, team building, working conditions, subject management, scientific research and so on. Find the weak links, take targeted measures and make continuous improvement, so that the departments of our hospital can move forward to the advanced ranks in the province.
3 discipline construction must establish rules and regulations and form a set of efficient operation mechanism.
There are no rules, Fiona Fang. Only by establishing rules and regulations can we form an efficient operating mechanism and ensure the development of the discipline to the established goals. Let the medical record managers make clear the purpose, objectives, responsibilities, responsibilities, task completion standards and reward and punishment measures, let them complete the task with good quality and quantity, unite and cooperate, and at the same time mobilize their work enthusiasm, stimulate their work enthusiasm, and let the general practitioners do a good job in discipline construction wholeheartedly. According to the characteristics and details of each post and work in the medical record management process, according to the relevant provisions of medical record management and the evaluation standards of tertiary general hospitals, the work quality standards, design process and implementation steps are formulated; Divide quality units according to posts and professional groups, set post staffing according to different workloads and titles, and divide responsibility areas. Various systems, responsibilities, plans and regulations on rewards and punishments have been formulated and strictly implemented. At ordinary times, self-inspection and mutual inspection work quality, the department has also set up a quality control team to check the quality of each link every month. If problems are found, they should be rectified and punished. We will reward those who find problems in time, correct others' mistakes, and be praised by hospitals and patients, arouse the enthusiasm of staff, and ensure the smooth development and operation of the discipline by interlocking, helping each other, checking at all levels, making clear rewards and punishments, and constantly exploring and improving the work.
4. Discipline construction and talent development are the key.
4. 1 academic leaders are the key factors that determine academic level, characteristics and advantages.
Academic leaders must have high academic qualifications, profound knowledge, superb professional skills, good management skills and noble medical ethics. At the same time, the director of the medical record room should be able to study hard, master the development trend of health information management at home and abroad, and be highly responsible for his work and career; Constantly explore department management, establish efficient and effective medical record service, and be good at planning medical record departments; Organize work reasonably and effectively; Make full use of and develop human resources; Guide employees correctly, master, control and coordinate the work between departments. The director of the medical record room should at least be a person with the title of deputy senior middle school or above, who is engaged in medical record management full-time. Only in this way can we grasp the development direction of the discipline, have a sense of responsibility and mission, coexist responsibilities and rights, and develop discipline construction better. Academic leaders are different from academic leaders. Academic leaders should be able to grasp the direction of discipline development, formulate discipline construction plans, determine discipline construction goals and major scientific research projects, grasp the overall situation, and actively explore the radiation effect of discipline construction benefits. The director of the medical record room of our hospital strives to follow the nine elements of academic leaders required by the dean: dedication, responsibility and dedication; Have a sense of innovation and development; Have high emotional intelligence and the spirit of unity and cooperation, be patient and willing to endure hardships, and do as many things as there are people in my heart; Must have the ability to drive the development of business medical level; Have an economic management mind; Scientific research should have quality and quantity; Be a teacher, preach and teach; Must have the ability to prevent and control medical risks; Must have quick execution. The director of medical record room pays attention to the construction of medical record management culture, constantly enhances the attraction, cohesion and appeal of this culture, effectively improves the comprehensive quality of medical record staff, and has formulated a five-year discipline development plan and talent training plan, gradually transforming the original traditional management mode of medical record room into a modern management mode, making our department the leading unit of medical record management discipline and the affiliated unit of the quality control center of medical record management specialty, and the director of medical record room the director of the quality control center of medical record management specialty and the leader of the expert group of disease operation code of city. Chairman of the Professional Committee of Medical Record Management of Haixi Medical and Health Development Center of the National Secondary Association.
4.2 The construction and development of disciplines cannot be separated from high-quality talent teams.
High-quality skilled talents are the main force to complete the discipline construction. Medical record management involves multidisciplinary knowledge and skills, and it is a highly specialized subject. Medical record managers should master not only certain knowledge of clinical medicine, basic medicine, hospital management and information technology management, but also knowledge of disease classification, surgical classification, computer, statistics and medical record management, especially the development of information technology requires medical record managers to have high computer application ability. Discipline construction talents should form an echelon. Only by means of "continuing education, special education, international cooperation, conference exchange and visit" can we build professional platforms at different levels for all kinds of talents and become the main force of discipline construction with high-quality skilled talents. At present, due to the management system and historical reasons, and some leaders don't pay enough attention to medical record management, many hospitals in China arrange some people who retire from clinical posts to the medical record room, which leads to the lack of medical record professionals, unreasonable cultural level, misplaced talents and aging personnel. At the same time, insufficient attention is paid to the training of medical record room personnel, which leads to the stagnation of the development of medical record management specialty. There were some problems in our hospital in the past. In view of these problems, with the attention of hospital leaders, we have established and improved the working mode of cultivating imported talents.
4.2. 1 The introduction of talents, the selection and allocation of reserve candidates for training academic leaders, and the cultivation of academic construction must have a good talent echelon, and it is very important to strengthen the cultivation and introduction of academic talents. In view of the problem of low academic qualifications, in recent five years, the quality control group recruited two graduate students majoring in clinical medicine, and the coding group recruited three undergraduate students majoring in hospital information management, in order to improve the cultural level of our department and change the aging phenomenon of personnel. Emphasis should be placed on strengthening the selection and training of reserve candidates for discipline leaders in discipline construction. Establish a pool of outstanding talents, implement directional tracking training, and cultivate reserve forces of subject talents. We encourage graduate students and undergraduates to keep learning, improve and perfect by giving them the necessary work and study guarantee. At the same time, cultivate their good professional ethics, strong organizational management ability, strong sense of responsibility and career pursuit. They have become the backbone of our discipline construction.
4.2.2 On-the-job training Because most of the staff in our department are transferred from other majors, they lack systematic and standardized medical record management knowledge and skills. In this regard, we adopt the way of passing, helping and bringing, so that personnel who have been trained in medical record management knowledge and skills can receive training regularly or irregularly; Each new employee must rotate in each post for 2 years and be allowed to take up the post after examination; It is stipulated that each person who goes out for further study and exchange should report and convey after returning to the department; In normal work, when encountering problems, the department personnel discuss and communicate with clinicians to achieve the goal of * * * improvement.
4.2.3 Increase the opportunities for medical record managers to go out for further study and training, strengthen communication with the outside world, formulate talent training plans, educate and train talents in a targeted manner in combination with the needs of discipline construction, professional expertise and job requirements, and send personnel to participate in professional study, training and learning exchanges at home and abroad. Junior professionals go out for study and exchange 1 ~ 2 times in three years, and those with intermediate and above titles go out for study and training exchange 1 ~ 2 times a year. In five years, * * * sent 1 person to study abroad, 2 people came to China to study, and 33 people participated in study, training and exchange. The staff of this department have broadened their horizons, accepted new knowledge and information, and improved the professional level of medical record management.
4.2.4 Strengthen the cultivation of personnel's professional quality and improve their professional level. Over the years, our department has undertaken the teaching task of medical record management theory course of health information management major in a university in Xiamen, sending personnel with intermediate or above titles to teach, and also teaching interns and interns in colleges and universities. Through lectures and lectures, the staff reviewed their professional knowledge and improved their teaching level. Department staff, especially those with intermediate titles or above, are required to publish an academic paper at or above the provincial level every year, and graduate students should try their best to have scientific research projects at or above the municipal level. In recent five years, the General Department has published papers 10 in academic journals above the provincial level. By writing papers, we can cultivate the scientific research ability of department staff and understand the development trend of disciplines at home and abroad. The core of discipline construction is talents, professional knowledge, teaching and scientific research ability are essential elements of discipline construction and development, and all-round development is the direction of efforts.
Refined and modern management methods are the basis and direction of discipline construction and development.
The development of the discipline depends not only on the personnel, comparative advantages, business prospects, the objective conditions of the unit and related policies and systems, but also on the situation of the surrounding units and the forecast of future development trends; Therefore, the development of the discipline should be fully evaluated, forward-looking and scientifically planned. With the rapid development of information technology, the specialty of medical record management is facing challenges, and the traditional management mode can no longer meet the needs of the new situation. It is necessary to change the management mode from refined and modern management to the advanced level of discipline construction. Only fine management can make the medical record managers fine, ensure the quality and improve the efficiency; Adopting modern management means can make the work more efficient, the data more accurate, and the medical record data more convenient and extensive.
5. 1 refined management
In the field of hospital management, there is a saying that "hospitals have advantages, disciplines have characteristics, and people have expertise". It is the key to build discipline brands and form strong advantages and characteristic technologies. In order to make the discipline construction in our college unique, meet the challenges of internal and external environment, enhance the motivation of discipline development and improve the core competitiveness of disciplines, we have taken the following measures.
5. 1. 1 Specialty refinement According to different job responsibilities and detailed rules, as well as the quality and specialty of each post, the posts and personnel are fixed, and everyone is engaged in a fixed professional development direction, so that their major can develop professionally, accurately and pertinently.
5. 1.2 refinement of system, responsibility, process and safety measures. The successful discipline construction is inseparable from the scientific compulsory system. The construction of compulsory system includes organization construction, rules and regulations construction, etc. Organizational structure is a dynamic structural system in terms of duties, responsibilities and rights, and its essence is a system of division of labor and cooperation to achieve organizational strategic goals. Therefore, according to each link, process and nature of medical record management, we have formulated corresponding systems, responsibilities and safety management measures from the processes of medical record recovery, sorting, binding, code entry, quality control, digital processing, filing and warehousing. Every medical record and every process are detailed, and the responsibility is linked to people, which improves the quality of medical record management.
5.2 Modernization of management means
5.2. 1 Use common management tools for management. We use seven management tools, such as checklist, AHP, Plato, causality diagram, scatter diagram, histogram and control diagram, to manage the quality of each link, which are used to collect and analyze the quality data of each link, analyze and determine the quality problems, and control and improve the quality level.
5.2.2 Modern technology and equipment are adopted for management, and barcode tracing positioning system is adopted for management. According to the information such as medical record number, patient and discharge date, barcode symbols are compiled by barcode making software. , printed and pasted on the cover of archived medical records; Scan with bar code reader, and display the patient's data on the computer screen; It is applied to all links and posts of medical record management to facilitate information inquiry and medical record positioning. Using the data of electronic medical records, the online application and online refund of electronic medical records are realized, and various levels of authority are formulated to facilitate medical personnel to consult and modify; At the same time, it is convenient for the medical record room to monitor the terminal quality online, collect data statistics and report the medical data needed by the Ministry of Health. Using digital medical record management technology, the archived medical records are digitized, so that all users can combine and fuzzy self-defined queries through the first page of medical records and other contents in medical records, extract, analyze and count them in the system, and export documents for application; It has the advantages of extensive, accurate, fast retrieval and statistical efficiency, true image recording, good appreciation, saving users a lot of time, occupying small space, saving medical record storage space and low cost. It meets the needs of medical record utilization in medical treatment, teaching, scientific research and management in our hospital, and has certain standardization, safety, practicality and advancement. Using the middle number color coding method, the medical record number is marked in different colors on the cover of the medical record, and the medical record number is distinguished by color, which is convenient for medical record personnel to identify the medical record number and avoid filing errors. The application of the above-mentioned modern technology and equipment has transformed the management of our department from the traditional management mode to the modern management mode, improved the quality, efficiency and accuracy of work, realized all-round, multi-functional and all-round quality service, and provided an important basis for the scientific decision-making and prediction of the hospital.
6. Strengthen team building and endow a set of incentive mechanism to keep pace with the times.
Team refers to a group of people who help each other, benefit from each other, unite as one, and strive to unify goals and standards. The team not only emphasizes individual achievements, but also emphasizes the overall performance of the team. On the basis of collective discussion, research and decision-making, information sharing and standard strengthening, the team emphasizes the fruits of victory achieved through the struggle of members, which exceeds the sum of individual achievements. We ask the members of the department to unite, understand and trust each other, brainstorm and work together. On this premise, give full play to the advantages of the team and mobilize the enthusiasm of different types of talents. Only when talents are constantly motivated can they innovate and improve, and can they maximize their potential and contribute to the collective goal. It is very necessary to establish an incentive mechanism that can mobilize the enthusiasm of all personnel. In addition to hospital regulations, we have also formulated a series of incentive mechanisms for department staff, such as: publishing papers, scientific research achievements, academic promotion awards; According to academic qualifications, work quality and attitude, formulate the priority order of going out to attend academic conferences, training and further study, study visits and promotion; Reward according to work performance and praise from all parties; Fairness, justice, openness and reasonableness are reflected in the treatment. Mobilized the enthusiasm and initiative of employees. After several years' exploration of discipline construction, the medical record room of our hospital has obtained the above practical experience, which is only for reference by peers. There are still many problems in discipline construction. We will continue to explore and constantly improve our work in order to improve the level of discipline construction, create disciplines with greater social influence, strive to maintain the core competitiveness of keeping pace with the times in the fierce competitive environment, and win the double harvest of two benefits.
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