Tapan Birkan, Balcı Yüksel, Sezen Adem, Ahmet Cenk Dikmen, Dikmen Davut Cem
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摘要

医疗记录是一种重要的资源,可用于证明向患者提供的医疗服务和评估所提供的服务质量。因此,准确地、定期地、详细地、及时地证明为可疑患者、病人、受伤人员和分娩人员提供的任何服务是非常重要的。医院的任何患者记录都包含有关人体健康的大容量数据。为了不同的目的,这些数据被检查、保存和注释。每个评论和基本信息都被存档,以便在需要时可以找到。在这项工作中,任何基金会医院的医疗报告的任何改进都用随机方法进行了回顾性检查。2004年至2013年,每年检查350例患者档案,共计3500例患者档案,涉及心脏科、心血管外科、骨科、神经内科、移植外科、普外科和肺科。医生在观察中指出,经检查的医疗记录中,大多数记录都没有填写完整。在2004年至2007年期间,医疗记录的填写率为80%,在2007年至2010年至2013年期间,这一比例提高到94%,实现了JCI认证和卫生部的审计。因此,在联合委员会进行认证审计的这些年里,人们注意到医疗记录有所改善。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Medıcal Records Management and Hospıtal Applıcatıon
Medical records make an important resource that can be used for evidence of medical care given to the patient and for evaluatingquality of provided service.Therefore it’s very important exactly and regularly certificate, in details and on time, any services provided to individuals whosedisease is suspicious, to patients, to injured person and to people who gave birth. Any patient records in hospitals contain data withhigh capacity about the human health. These data are checked, preserved and commented for different purposes. Each comment andbasic information is archived in order to be reached in case of need. During this work any improvements made in medical reportsof any foundation hospital were retrospectively examined with a casual method. Between 2004 and 2013, 350 patient files for everyyear and totally 3500 patient files from cardiology, cardiovascular surgery, orthopedics, neurology, transplantation, general surgeryand pulmonology departments have been examined.In their observations doctos noted that the examined medical records most of the records have been incompletely filled in. The ratioof filling medical records that in the period between 2004 and 2007 years made 80%, in the period between 2007 – 2010 – 2013 raisedto 94%, where the audits of JCI ac creditation and of the Ministr y of health were realized.Consequently: an improvement in medical records has been noticed during the years where JCI accreditation audits have been realized.
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