通过系统文献综述法,从《医院评审国家标准》审视病历工作部门的风险管理实施情况

Khairunnisa Khairunnisa, Nina Rahmadiliyani
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引用次数: 0

摘要

不可否认,医院在工作活动中可能会产生不必要或意想不到的负面影响,病历工作部门就是其中之一。本研究的目的是根据《国家医院评审标准》确定病历工作部门风险管理的实施情况。采用的研究方法是系统文献综述,搜索策略是使用谷歌学术结果标准,关键词为 "病历工作单位的风险管理或基于 SNARS 的病历工作单位的风险管理"。研究结果来自对 6 篇期刊论文的深入分析,所查阅的期刊论文与根据《国家医院评审标准》在病历工作单位实施风险管理之间存在联系,其中发现的问题平均出现在《国家医院评审标准》第 12 条标准中,该标准涉及诊断代码标准、程序/操作代码、符号、缩写及其含义的确定;《国家医院评审标准》第 13 条标准涉及在医院为每位患者提供病历;《国家医院评审标准》第 13 条标准涉及医院规章制度,该规章制度确定了医院中那些需要对病历进行风险管理的人员。MIRM 标准 13.3 涉及专业护理人员 (PPA) 在记录后通过书面标识填写医疗记录,MIRM 标准 13.4 涉及绩效改进工作和医院定期评估或审查医疗记录。从这些条款中可以看出,医疗记录工作单位的风险等级分为 "可接受"(风险强度降到最低)到 "重大"(需要技术改进)。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Implementation of Risk Management in The Medical Records Work Unit Reviewed From National Standards For Hospital Accreditation Through A Systematic Literature Review Approach
The hospital, there is no denying the possibility of unwanted or unexpected negative impacts in work activities, one of which is in the medical records work unit. The aim of the research is to determine the implementation of risk management in the medical records work unit in terms of the National Hospital Accreditation Standards. The research method used was a Systematic Literature Review with a search strategy using Google Scholar results criteria with the keywords "Risk management of medical records work units OR Risk management of medical records work units based on SNARS". The research results were obtained from an in-depth analysis of 6 journal articles, there was a link between the journal articles reviewed and the implementation of risk management in the medical records work unit in terms of the National Hospital Accreditation Standards where the problems found on average occurred in MIRM 12 Standards related to the determination of diagnosis code standards , procedure/action codes, symbols, abbreviations and their meanings, MIRM Standard 13 relating to the provision of medical records for each patient in hospitals, MIRM Standard 13.2 relating to hospital regulations which identify those who have the right to fill in patient medical records and determine the contents of medical records and format medical records, MIRM Standard 13.3 relates to filling in medical records by Professional Care Providers (PPA) by writing identification after the recording is made and MIRM Standard 13.4 relates to performance improvement efforts and hospitals regularly evaluating or reviewing medical records. The risk levels in the medical records work unit from these articles show that the risk categories are "Acceptable" (the intensity of risk is reduced to a minimum) to "Substantial" (requires technical improvement).
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