The case room, that is, the case section, the department's work is mainly on the case of patients who have been discharged, through the case management, conducive to the study of the condition, the following is what I have organized for you on the case management of individual work summary, if you like can be shared with your friends around you喔!
Case Management Individual Work Summary 1
20 - year in the hospital leadership of the strong support, the cooperation of the clinical departments, the actual work of the case management committee has achieved certain results, is now the work of the year is summarized as follows:
1, this year, our hospital in the organization of the entire medical staff to learn the Guangdong Provincial Department of Health issued by the Guangdong Provincial Medical Record Writing and Management Standards, on the basis of the May formulation of the "inpatient medical record writing rewards and penalties rules," for clinical medical personnel in the writing of the medical record is difficult to correct the problem of making clear requirements and the development of the rewards and penalties, mainly to reward the main incentives for the motivation of medical personnel, so that the quality of the case to another level, the B-class medical records than the previous year was greatly reduced.
2, in response to the widespread phenomenon of delayed filing of medical records, this year still strengthened the recovery of medical records link monitoring, responsibility to the individual, the implementation of monthly verification of medical records filing, according to the hospital "hospital management rules", the delay in the implementation of a strict penalty system for those responsible for the discharge of the medical records on time to shorten the time of the recovery significantly.
3, this year increased the outpatient emergency medical records of quality control management, case management committee clearly put forward the emergency medical records of the writing norms and the principle of informing the condition, requiring doctors, nurses *** with the cooperation to complete the pre-hospital emergency medical records of the standardized writing and signing of the informed consent form, and each case of pre-hospital emergency medical records of the patient to be regularly sorted out archives, from the first link to eliminate The medical safety hidden danger from the first diagnosis.
4, strengthened the implementation of informed consent, informed notification and informed choice system, focusing on checking the implementation of the surgical safety verification system, and effectively improve patient satisfaction and quality of medical records, reduce medical risks, and protect medical safety.
5, to strengthen the quality management of outpatient medical records, the quality control section of the quarterly outpatient medical records random checks, for the existence of problems to take the form of naming and notification of supervision and rectification, and effectively improve the quality of outpatient medical record writing.
6, strengthen the supervision of the implementation of the quality control work of various departments, departments as required to convene a monthly, the hospital held a quarterly meeting of the quality control of case management staff work conference, so that the section-level, hospital-level quality control found in the medical records of the existence of the problem of feedback and rectification in a timely manner; at the same time, the implementation of the quality of the management of the case of accountability system for the B, C medical records of the doctor in charge of the doctor, the quality control of the doctor and the department The person in charge, according to the hospital's "hospital management rules" for punishment, effectively improve the quality of medical record writing.
Case Management Individual Work Summary 2
Case information is one of the important departments of the hospital, the hospital information work plays a pivotal role. Since its opening, the case room in the hospital leadership of the strong support, clean up ideas, clear tasks, adhere to the guiding ideology of information work for the scientific management of hospital services, closely around the hospital development and construction as the center, the full performance of duties, highlighting the comprehensive information work for the management of the hospital services for the focus of the clinical front-line services, the successful completion of the opening of the various tasks since the promotion of the development of information technology construction of hospitals, the development of a stable operation. Now the 20 - year case room work is summarized as follows:
First, the construction of the case room and the preparatory work.
In the month before the opening of the case room, we actively to the post and devote themselves to the construction and preparation of our case room work.
(a) the case room of the warehouse remodeling and construction work.
(1) the original case room two storage space available were about 48.9m2 and 24.7m2, in order to increase the storage of cases of the reserved space, the case room of one of the storage space is relatively small storage room and about 46.2m2 of the reading room for the transfer.
(2) Because of the reduction in office space due to the realignment of the case room storage room, a space of about 11.3m2 was expanded in front of the case room storage room for reception inquiries and photocopying.
(ii) Infrastructure preparation for the case room.
(1) The case room has special characteristics, there must be a good fire, moisture, humidity, insect and other facilities to reduce the adverse factors on the case carrier. Our case room lighting system unified adjustment for explosion-proof lamps, and the installation of fire and burglary doors as well as access to the use of password electronic access control system. At the same time, we also requisitioned the case file disinfection cabinet, air sterilizer, dehumidifier and other equipment.
(2) Considering the low utilization of space in the warehouse, the use of intensive cabinets is a waste of resources and does not meet the five-year reserve space for the storage of cases, we use the iron frame to store cases.
(3) actively communicate with clinical departments.
In order to smoothly carry out the work of the case room, in the pre-opening period, our department staff visited each clinical department to educate them on the rules and regulations of the case room of the South Hospital and its precautions, and listen to the views of clinical departments.
Second, improve the management level of the case room, and further improve the rules and regulations.
The case management program is the focus of the case management work, the borrowing of cases, entry, quality control and other links, according to the corresponding system. South Hospital as a new hospital, our department has higher requirements in the work and improve the system in the Department.
(a) the management of discharge medical records filing regulations. The implementation of twice a week to sign for the discharge of medical records.
(b) The loan system of archived medical records. We strictly implement the archived medical records "only in and out" of the loan system, to prevent the loan of medical records, to ensure that the case is only in the case room to consult.
Third, do a good job of departmental functions.
The whole department obeyed the hospital arrangements, pay attention to their own work, and work together to complete the work.
(a) Case preservation.
The storage and retention of medical records is an important task in case management, and the medical records library is a key link in the protection of medical records. Because of the limited conditions of our hospital, the medical records library is tense, under the existing conditions, the library can keep clean, neat, dry, to do fire, heat, moisture, humidity, insect moths, mildew and so on. Recovered medical records can be timely disinfection, finishing, binding, recording, filing, color-coded, shelves, to ensure the integrity of each medical record, not good, leakage.
According to the International Classification of Diseases and Codes (ICD-10) and the Classification of Surgical Procedures (ICD-9-CM-3), the disease classification and coding is done for each discharge medical record. As of November 20, 20--year, the case room completed the signing, organizing, quality control, coding, filing, and color-coded shelves of 6,304 medical records.
(ii) Final quality control of medical records.
We check and focus on the medical records as comprehensively as possible. We find that there are problems with each medical record, and promptly notify the doctor to the case room to modify. Larger problems are communicated to the doctor in a timely manner to remind future corrections. Eliminate the revision of medical records after filing, do not give doctors the illusion of being able to revise medical records and dependence on the case room. At the same time, the clinicians to supervise, according to the writing specification of the first page of the case, discharge summary, admission records and other writing problems occurring uniform correction.
(C) borrowing and copying.
Borrowing and copying is a window position in our department, our department staff can do their duty according to the regulations without losing flexibility to do this work, by the majority of people praise praise. The patient copying process, we strictly enforce the system, flexible grasp of the principle, so that we can avoid disputes with patients, and do a good job of hospitals for patients in the medical link of the `end of service.
(D) on the statement.
Regularly reported weekly to the hospital discharge medical records filing rate, defect rate and other statements. Monthly summary and monitoring of the filing of discharge medical records, effectively improve the filing rate of medical cases, discharge medical records monthly filing rate of about 97.97%. The statistics in the report are strictly audited, and errors and inaccuracies are changed in time to make them real, accurate, and well documented.
Fourth, the breakthroughs and achievements of the work of the case room.
We in the South Hospital in the inheritance of the Department's rules and regulations and management methods, to play our hospital's advantages, to achieve better results.
(a) The implementation of the 7-day filing system.
Ensure the timeliness of the filing of cases, improve the phenomenon of delayed filing of cases, facilitate the timely statistics and effective use of case information, and significantly improve the filing rate of cases to meet the latest implementation details of the accreditation standards for tertiary general hospitals.
(ii) The use of color-coded filing cases.
Our department has its own unique color-coded filing method to mark each medical record. This eliminates the need for wrong shelves and facilitates the identification of quickly extracted cases.
(C) The "closed" loan system of medical records.
Avoid the circulation of the case, to ensure that the case is not lost.
(d) Outside the scope of our duties, we make full use of the time to carry out quality control of the case.
The quality control check includes whether the information on the first page of the case is filled out accurately and completely; whether there is a lack of various medical documents; whether the medical documents are missing signatures; whether to check whether to clip the wrong report of others; whether to check whether the report is forged; and whether to check whether the modification of various types of medical documents is in line with the specifications for writing medical records.
(E) more standardized archived medical records recall and revision of the approval process.
The case room received the application form for the recall and revision of medical records, timely communication of whether the medical records have been copied, if the patient has been copied medical records, refused to allow clinicians to modify.
(vi) Sterilization and preservation of medical records.
Our department immediately after the recovery of the case with a document disinfection cabinet for ozone sterilization sterilization, and the same day the use of air disinfection machine for case room disinfection and sterilization. Regularly every month in the case storage room for air disinfector disinfection, dehumidifier dehumidification, to protect the case against mildew, insect moths and so on.
V. Results of business learning.
Our case room staff are not case specialty graduates, but we are actively participating in learning training and other opportunities to enhance their business level. In 20 - June, the department to participate in the eleventh hospital case information management academic exchanges conference, while the "case home information quality management problems" academic papers and "talk about the experience of the damage coding" academic papers in the conference was accepted and exchanged at the meeting.
The case room is a comprehensive coordination, neutralization and service work, should have a strong sense of enterprise, a high sense of responsibility and pragmatic work attitude. In the future work, the department will continue to learn and use advanced digital management methods of case information, and strive to carry out new business, new technologies, and make greater contributions to the hospital's case management. Finally, we plan to improve the following aspects of work in 20--year:
1, at present, our hospitals use a series of numbers, this method of dividing patients' medical information is not conducive to the patient's medical treatment, has resulted in a waste of manpower and resources, and it is difficult to provide the patient's complete medical information. Can be implemented in 20 - year outpatient observation room patients and hospitalized patients hospitalization number differentiation, to ensure that the hospitalization medical records can be continuous number, to facilitate the management of the case room.
2, whether the patient access to photocopy the case to provide telephone appointment service, reduce patient waiting time, to avoid patients because the medical records are not archived and many times to and from the hospital to apply for a copy of the doctor's complaints.
3, the case room in the ground floor, often faced with pipeline leakage, the case room library construction urgently need to be examined by the hospital to place a suitable location to ensure that the case can be moisture-proof and waterproof.
4, improve the business level. Engaged in case management personnel from other professions, the lack of professional or related professional personnel, more need to strengthen our business learning, and constantly improve their own business level. Whether you can provide more training opportunities to learn DRGs as well as the qualification of the coder.
Case Management Individual Work Summary 3
20 - June 6, I came to the People's Hospital to officially start work. At the beginning, I did not have any work experience, in the face of such a point of work, my heart has an incomparable contradiction of complex feelings and great pressure. But I think this is a fledgling graduate for me to experience and hone, so I confidently embarked on this unforgettable journey.
In reality, I have been working hard to learn and care for the leadership, as well as the enthusiastic help of colleagues, I gradually gradually integrated into the people's hospital in this big family. Here I have learned to be a man of reason, but also learned to deal with people. I strictly abide by the rules and regulations of the hospital, conscientiously perform the duties of the internship nurse, strict requirements for their own, never late for no reason, early retirement, down-to-earth work, on time and actively participate in the activities organized by the hospital.
The case room is a comprehensive work, he is the coordination and service of the `work, an excellent case room medical staff must have a strong sense of enterprise, a high sense of responsibility and pragmatic work attitude, but also has a strong political quality and technical level, rigorous and sophisticated work style, dedication to work. But I always believe that as long as I work hard and treat each task seriously, I will be able to be recognized by the leadership, colleagues and patients.
I entered the hospital the first task is to familiarize with the working environment, learning computer case input system, with the leadership of the various departments of the timely copying and distribution of information, the unfinished cases in a timely manner to notify the delivery and so on. I have always practiced "good leadership, good service department, good service to patients.
Case Management Individual Work Summary 4
The case room is a comprehensive coordination, neutralization of the work of the service, a qualified staff of the case room because of a strong sense of commitment, a high sense of responsibility and pragmatic work attitude, with a strong political quality and business talent, rigorous and capable of working style, the The spirit of the present. I always trust that as long as their efforts, serious treatment will be recognized.
I entered the hospital important task is to familiarize themselves with the working environment, learning computer case input system, with the leadership of the various departments of the material in a timely manner copying and distribution, unfinished cases in a timely manner to notify the delivery and so on. I have always practiced the "good leadership, good service, good service to patients," the work of the concept, conscientiously complete the work of the leadership arrangements, with the leadership of the successful completion of the work task, to develop comprehensive quality, enhance the work of talent. Do not let the work arranged by the leadership in their own delay, do not let the handling of matters in their own hands accumulation, do not let all kinds of errors in their own body, do not let the copying of medical records of patients in their own cold, to cultivate a sense of service. Precise understanding of the important role of case management, to enhance the understanding of the modernization of case management, encounter lawsuit medical records timely report to the leadership.
Always keep a clear political mind, put in the right position, try to organize the work in a well-organized manner. "Both come, then peace of mind" is with this mood I tried my best to learn. The full enthusiasm for the cause and a highly responsible attitude into the work of resolute obedience to the leadership and service to patients. Seriously follow the implementation of hospital rules and regulations and labor discipline to maximize patient satisfaction.
I very much like, cherish this post, it is both a furnace, but also a stage, both can exercise their own, 20 - year secretary of the duty report can also show their own. Looking back on this period of time, I basically completed my work, which is inseparable from the support of the leadership and the help of colleagues, here to the leaders and colleagues to express my heartfelt thanks!
The above is a summary of my thinking, work, incomplete and imprecise, please leaders and comrades to criticize and correct. In the future work, I will do a good job of personal work plan, so that their work to do better. Live up to the leadership's expectations of me.
Case Management Individual Work Summary 5
20 - year in the leadership of the care and cultivation and the help of colleagues, and constantly strengthen the business learning, work excellence, and the department staff unity and cooperation, **** with the efforts to successfully complete all the work, the individual business capacity has made some progress, now the work of the learning situation is summarized as follows:
First, ideological:
Love for the motherland, love for the Chinese ****production party, love for the work; consciously safeguard the unity of the motherland, safeguard the unity of the nation, against ethnic division, and clearly oppose the "three forces"; love and dedication to work, and do their duty. Timely completion of the work entrusted to the leadership, and the hospital staff of various departments to deal with good relations, pay attention to their own words and deeds, treating others well, in good faith, broad-minded; in the work of maintaining a normal heart, the proper handling of people and things, especially for patients and families need to have enough patience, and in a timely manner to understand the needs of patients and their families, as far as possible to help those in need of help; conscientious study of the law, to know, understand, abide by the law, and to do so, to know, understand, abide by the law. Do know the law, understand the law, abide by the law, seriously study the party's mass line education and practice activities, and in the activities of the criticism and self-criticism, humbly accept and correct the comrades of the opinions I put forward; the total duty to pay attention to the security work, and constantly supervise outpatient and emergency security personnel to do a good job of registering, checking the work from time to time to inspect the department and solve the problems found in a timely manner.
Second, the work:
With a positive, conscientious and responsible attitude towards work, conscientiously abide by the rules and regulations, obey the hospital and departmental arrangements, keep the office environment clean, and do a good job in fire prevention and theft. Work is not afraid of hard work, not afraid of tired, to work rigorously and meticulously. Since the transfer into the case room, seriously study the case room duties, rules and regulations and coding, statistical knowledge, humbly to the leadership, seniors to teach, as the saying goes "different lines like a mountain" to the case room for the first time everything has to be learned from scratch, so I use my spare time to continue to recharge their own batteries, read professional books, to join the case-related QQ group, with seniors to learn coding-related knowledge. Learning coding related knowledge. In the hospital to provide me with the opportunity to go out to study, I cherish every opportunity to learn, abide by classroom discipline, take good classroom notes, in advance to organize their own work encountered in the difficult problems, confusion, timely to the teacher to ask for advice and the lecturer and the teacher to establish a good teacher-student friendship, which provides a great deal of help in future work, through the study abroad, will be outside of the hospital to bring back to the hospital a full range of diagnostic coding technology to improve the accuracy of the coding. The accuracy of coding has been improved. Since we took over the statistical reporting in July, with the help and cooperation of our sister departments, we have completed the monthly and quarterly reports as well as the network direct reporting on time. Through continuous learning and accumulation, the efficiency and quality of work have been greatly improved, and the work tasks have been completed better.
Third, attendance:
Strictly abide by the attendance system, on time to participate in the hospital and the department of the various studies, meetings and exams, so that not late, not early departure, not off duty, not series of posts, the whole year, full attendance, no sick leave, personal leave, annual leave due to the need for work there are four days did not take.
Fourth, the achievements:
Learned the coding work and obtain the corresponding qualification of the autonomous region, learned the case statistics work, can independently complete the monthly statement, quarterly statements and network direct reporting, and can be issued on time statistics statements, complete continuing education credits 31 points.
Of course, in many ways I still have many deficiencies, not enough consideration, not enough detail. Now through the summary of the recognition of their own problems, determined to improve and solve the work in the future, timely completion of the tasks given by the leadership to improve their own quality, in the future work and life to determine their own goals, and to their own customized goals and go to work hard.
Case Management Individual Work Summary Related articles :
★ 2020 Case Room Individual Work Summary
★ Case Department Individual Work Summary
★ 2020 Case Room Individual Work Summary(2)
★ Case Room Annual Work Summary Sample
★ Case room annual thought work summary
★ 2017 case room individual work summary (2)
★ 2019 medical department individual work summary
★ 2019 medical department individual work summary sample
★ hospital individual work summary report
★ 2020 doctors individual year-end work summary of the latest selection of 5