Seven months of time is like a flash of lightning as quickly as it was so rushed through. This is my entry into the Chinese medicine hospital "moment". Looking back on this only seven months of time, for me, it is so full, memorable, thinking ......
May 4, 20XX, I came to start working in the hospital. The first time I worked for me without any work experience, I have an immense contradictory mood and pressure. But I think this is also a rare experience and training for me, so I embarked on this journey with confidence. Through my own period of study and leadership care, the help of colleagues I gradually integrated into this big family. Here I realized the truth of being a human being and learned how to deal with people. I strictly abide by the rules and regulations of the hospital, conscientiously perform the duties of internship nurses, to Marxism-Leninism, strict requirements for themselves, not late, not early departure, down-to-earth work, on time to participate in a variety of activities organized by the hospital.
The case room is a comprehensive coordination, neutralization and service work, a qualified case room staff because of a strong sense of enterprise, a high sense of responsibility and pragmatic work attitude, with a strong political quality and business capacity, rigorous and competent work style, the spirit of the present. I always believe that as long as their efforts and seriousness will be recognized.
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 the "good leadership, good service, good service, good service to patients" concept of work, conscientiously complete all the work arranged by the leadership, with the leadership of the successful completion of the work task, to develop a comprehensive quality, improve the ability to work. Do not let the work arranged by the leadership in their own delay, do not let the handling of matters in their own hands backlog, 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, and cultivate a sense of service. Correctly understand the important role of case management, improve the understanding of the modernization of case management, encounter lawsuit medical records timely report to the leadership. Always keep a clear political mind, set the right position, and try to organize the work in an orderly manner. "If you are here, you are safe" is with this mood I try my best to learn. The full enthusiasm for the cause and a highly responsible attitude into the work of resolutely obey the leadership and service to patients. Strict 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 to exercise their own, but also to 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, I would like to express my heartfelt thanks to the leaders and colleagues! The above is a summary of my thoughts and work in the past six months, incomplete and inaccurate places, please leaders and comrades to criticize and correct. In the future work, I will do a good job of personal work plan to make their work better. Live up to the leadership's expectations of me.
The first half of the case work summary Part 2Six months of time rushed by, like lightning. This is the first moment I entered the people's hospital. Looking back on this short six-month period, it is so full, wonderful and memorable, now the individual work summary is as follows:
June 6, 20xx, I came to the People's Hospital officially began to work. At the beginning, I do 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 the reality of work, I have been through a period of hard learning and leadership of the `concern, as well as the enthusiasm of colleagues to help, I gradually gradually into the people's hospital this big family. Here I 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 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 service leadership, good service department, good service to patients.
Summary of the first half of the work of the Department of Case 3China's national economy since the reform and opening up to rapid growth in successive years, the pace of modernization of the hospital has also had rapid development, can show the progress of modernization of the hospital's information - case, statistics, in the medical treatment, teaching, scientific research and management services at the same time, but also from the aspect of data, the hospital modern science and technology, advanced instrumentation, and the development of the hospital's modernization. The hospital modernized science and technology, advanced equipment and service attitude of the degree of change.
China's hospitals, medical records, statistics in the last decade, the great changes, the speed of the common people can not imagine, it has been in many aspects of international standards, many hospitals are about to go hand in hand with the developed countries in the world. Specific performance:
First, the past case card, registration, statistical tabulation are manual, and now use the computer.
(a) in the past to do the classification of diseases, medical (surgical) operation classification, name, doctor and follow-up index card; hospitalized patients, dead patients, cadaveric pathology examination are equipped with a register, all manual operation. Now most hospitals in the outpatient registration room, hospitalization, wards, cases, statistics section (room) are equipped with computers, these departments will be divided into the "first page of the case," respectively, according to the requirements of the seriousness and responsibility of an entry into the computer, that is, you can call up a variety of index cards required and a variety of registration projects. Health administrative departments required to report the "hospital inpatient disease classification" statistical report data, can also be called up from the computer as required.
(b) in the past, the hospital inpatient admissions, discharges (including death, the same below) the number of daily reports by the clinical departments to fill in, and fill in the "discharged patient card" (case home page summary) as the basis of the discharged patients, statistics and summary compilation of the previous working day's hospital admissions, discharges, the number of daily reports, sent to the hospital leadership and relevant departments. The report will be sent to the hospital leadership and the relevant departments. Now, as long as each clinical department enters the number of admissions and discharges on the previous working day into the computer after work, the medical records and statistics office can call up the "daily report on the number of admissions and discharges of all hospitalized patients". The hospital leadership and the relevant departments can also be transferred from the computer, the data are accurate, uniform, and fast.
The daily reports stored in the computer are accumulated over time, and the daily, monthly, quarterly, semi-annual, and annual reports required by the health administration or hospital leadership can be compiled.
Second, in the past, the hospitalized case row shelf is generally used in accordance with the order of the hospitalized case number.
This method is easy to find cases, back to the more troublesome, once back to the wrong place, the next time it is difficult to find. Now some hospitals: such as Concordia, 301 has adopted the "tail number rack method" to find back to the very convenient, not easy to misplaced, can improve the efficiency of the work several times, should be vigorously promoted.
Three, the case to save.
According to the Ministry of Health on August 29, 20xx, Decree No. 35 issued by the "Regulations on the Management of Medical Institutions," Article 35 of the medical institutions of the outpatient case retention period shall not be less than 15 years; inpatient case retention period shall not be less than 30 years. Calculated on the basis of 30 years: 1,000-bed hospital, the average number of patient days in hospital 13 days, the annual turnover of beds 26 times, the average annual number of discharges of about 26,000 people, 30 years should be preserved in the case of 780,000 copies. General per 10,000 cases occupy about the case library (area): 5 square meters, *** need to occupy the case library 390 square meters, the total floor area of 585 square meters. According to the protection requirements of the building of the case library, the cost per square meter is 4000 yuan (national average) or so, including the case shelves within the need to invest 250-300 million yuan.
If only 10 years of cases stored annually, the first 20 years of 520,000 cases to do microfilm or enter the CD-ROM storage, can be less than 390 square meters of case library, less construction investment of 1.6 to 1.9 million yuan. With half of the investment savings that can solve the purchase of microfilm or manufacturing CD-ROM equipment, as well as the production of microfilm or CD-ROM case. It is better than the case library to save the characteristics are:
(a) with micro or CD-ROM storage is the beginning of 20 years, and then 10 years to 30 years, and so on the hospital micro or CD-ROM storage of cases year by year, in fact, is an increase in hospitals for the medical research and teaching of invaluable medical resources.
(b) the storage of microfilm or CD-ROM using special filing cabinets, can do "five defense", it is safer than the case shelf preservation.
(c) The use of microfilm or CD-ROM storage case is the trend of international countries, is a sign of modernization of case management.
(d) With the development of science, microforms, CD-ROMs, a class of products prices are gradually declining trend, the investment will gradually reduce, but also reduce labor intensity.
Fourth, the past hospital information department set up cases, statistics, books, computers, originating in the last century 80 years.
Held in Nanjing, "National Academic Conference on Case Statistics" drafted by the "medical hospital case, statistical work requirements" and the Ministry of Health "hospital hierarchical management methods "In the 1990s, the world's developed countries hospital case (including statistics), the development of information organizations, computers are information (case statistics) work tools. As a result of frequent international academic exchanges, the domestic economic development of the faster areas of Beijing and Tianjin, the Yangtze River Delta, the Pearl River Delta and some hospital statistics and into the case (and case statistics merger is not the same), the China Hospital Association, the Professional Committee on Case Management has prepared the appropriate software, case, statistics required data can be transferred from the computer. Cases, statistical work and organizations, with the use of computers will be integrated.
Fifth, case statistics play a leading role in hospital management, case management statistics, hospital management to the high development, and gradually standardized. Hospital case statistics merger, the case to achieve a good write the case, manage the case, use the case and the case will be "home page" into the computer, you can output the necessary medical statistics indicators for reference to hospital management, which Xiang case statistics on the completion of the institutionalized, standardized and programmed.
This is to take the road of socialism with Chinese characteristics (Western countries in the hospital case is a separate set of results). This result requires professionals with knowledge and experience in hospital case statistics and hospital management, serious research, summarization, and make conclusions. This is an innovation, which will not only change the status quo of hospital case statistics and hospital management, but also have an impact on the national hospital management.
The first half of the work of the case summary Part 4In the first half of 20xx, under the strong support of the leadership of the hospital, under the correct leadership of the section chief, the case room staff clear focus on the work of the implementation of the work of the task, the full implementation of the work of the duties for the clinical front line and patient service. Now the six-month work is summarized as follows:
First, the completion of operational work
The first half of the case room completed the recovery of 3,287 copies of medical records, coding entry, filing shelves; borrowing 555 copies of the medical records (quarterly review of 467 copies). Photocopying medical records 846 times. Reported 3,287 western medical cases on the first page through the Sichuan Province Health and Family Planning Statistics Comprehensive Collection Network System, with an average score of 96 (target score of 90), and 195 maternal deliveries were reported. Monthly, quarterly and actual reports were completed on time and with high quality. Monthly monitoring of medical quality data and writing analysis reports.
II. Problems
(a) Low filing rate of the recovery period (7 days) of medical records in the hospital as a whole (except for obstetrics and gynecology).
(b) There are deficiencies in the writing of medical records:
First, missing items;
Second, logical errors;
Third, the cause of trauma is very general;
Fourth, the coding is not accurate enough;
Fifth, carelessness.
(c) Insufficient space for storage of medical records. Because of the first half of this year, compared to a larger volume of business, the case room space is seriously inadequate, three-dimensional file cabinets a loaded 1,000 copies, is now only the remaining 9 file cabinets, at most, can only be loaded 1.5 years of time will be all used up. And the medical record retention period is 30 years.
(D) statistics do not pay attention. Medical statistics are not highly valued, and it is more difficult to collect data for reporting.
Third, improvement measures
In the second half of the year, for the four problems mentioned above efforts to find a solution to put forward corrective measures.
First, study and implement the case management system, hard rewards and penalties;
Second, to improve the scope of the review of medical records, individual problems with the medical records to grasp the focus;
Third, the case room space is insufficient, the three-dimensional cabinets are seriously insufficient, must be purchased;
Fourth, to strengthen the publicity on the work of the statistics to raise awareness and grasp the quality of the data, the statistical work is included in the section performance appraisal.
The first half of the case summarizes the work of Part 5
First, carry out the work
1. Successfully completed the uploading of the home page of the case
In May this year in the case of time constraints, fewer staff, heavy task, the whole section of the staff work overtime, in a timely manner, to complete the conversion of the coding dictionary library in the Information Technology Section of the great help, the work. With the great help of the Information Section, the uploading of the first page of patient cases for the three years from 20xx to 20xx was completed. In the process of uploading the first page of the case, the first page data are constantly improved and supplemented, so that the uploading rate and accuracy of the first page of the hospital's cases have reached 100%.
2. In the quality of medical care, strictly control the quality of the first page of the case
Tertiary hospital performance evaluation of 55 indicators, 26 directly from the first page of the case, in order to improve the quality of the first page of the hospital to ensure the accuracy of the case data, scientific and logical, we have carried out the following work.
① Organization of the hospital's clinical departments and medical staff to fill out the standard case home training.
② The first page of the case into the quality control management. In the work of the problems found in a timely manner in the form of microblogging feedback to clinicians, and at the end of each month will be the first page of the department in the form of paper feedback to the director of the department, the director of the department to fill out the corrective comments signed back to the case room. At the same time, at the end of each month, the specific problems of the home page of each department, the home page pass rate in the form of an electronic version of the report to the Medical Department, the quality control assessment of each department.
Second, problems encountered in the work
1. tertiary public hospital performance assessment indicators of the day surgery accounted for the proportion of elective surgery, discharged patients minimally invasive surgery accounted for the proportion of patients, due to the hospital does not have a clear directory of day surgery catalogs and minimally invasive surgery catalogs, the statistician due to the different conditions of retrieval lead to inconsistent data.
2. Surgical complications are not reflected in the paper front page, and the doctor omitted to fill in the front page of the electronic case, such as postoperative hemorrhage, hematoma, incision cracking, incision fat liquefaction, etc., which were not filled in the electronic version of the surgical complications, and were not reported to the medical department, and the department did not record, etc., resulting in the inability to accurately count the data.
3. The current case staffing is seriously understaffed. Unable to post grouping, and no professional statisticians and coders. The department is currently staffed by 7 people, 3 for quality control (2 medical, 1 nursing), 1 for statistics, and 3 for coding, as well as photocopying medical records, filing, binding, finding and shelving. Two of these three people are facing retirement, and the other one just came to the case room this year. Especially now there are 115 items in the performance statistics index of tertiary public hospitals which are reported by our department, and we need to upload the homepage data and report the statistical indexes regularly every month, which is a heavy workload and a heavy task, and at present, there is only 1 statistician in our department, who is not graduated from the statistics program and has not had any systematic training, and there is no replacement, which is a great pressure. In the face of the upcoming reform of the DRG payment system, case coding will become an important basis for payment, but the department coding staff non-professional graduates, and has not been systematically trained, so the case coding staff can not be fully competent.
Third, Plan
1. Further standardization of the first page of the case, increase the management of the first page of the case, the need for the relevant management of the hospital, the clinicians and the case staff *** with the efforts of the control of the quality of the case of the responsibility for the implementation of the layers to the individual, a clear responsibility to further increase the rewards and penalties, pay attention to the standardization of training.
2. Equipped with professional statistics and coding staff, enriching the case section.
3. Strengthen the business training of coding staff, organized in batches of coding staff to go out to study and improve their own business level.
Summary of the first half of the work of the Department of 6
20xx, in the hospital leadership of the strong support of the staff of the Office of the Office of the clear thinking, clear tasks, adhere to the work of the case for the hospital scientific management services guiding ideology, the full performance of their duties and responsibilities, highlighting for the clinical front-line services, and the successful completion of the current year's work of the Office of the work of the various tasks. Now the work of the year is summarized as follows:
First, the completion of the year's business objectives
Section personnel to obey the hospital arrangements, pay attention to the work, at any time or temporary urgent need for the work of the whole section, the whole section staff to work together to complete. Case room throughout the year **** completed the collection of 7845 medical records, organizing, binding, coding, microcomputer home page entry, filing and shelving work. Borrowing and copying is a window position in our department, and the caseworkers are able to do this work dutifully in accordance with the regulations without losing flexibility. Statistics show that: the hospital *** access to 18,650 cases, of which the Office of the Medical Insurance Office borrowed 7845 cases, sense of management *** borrowed 7845 medical records, hospital quality control group borrowed 1,534 copies, the Medical Department borrowed 102 copies of the case, clinical pharmacy office borrowed 1,026 copies of the case, the clinician borrowed 224 copies to send to the higher level of quality control of the quality of the medical records of the hospital 74 copies. 20xx *** photocopying 252 cases.
Second, the "second hospital review" standards for the work of the center
In preparation for the creation of the work of the hospital level, the department staff can repeatedly study the "second hospital review rules", "rules" in the case of the analysis of the requirements of the case, one by one to conduct a comparison, the benchmark to find the difference, step by step. The department has been analyzing the requirements of the rules on medical cases, comparing them with each other, finding the differences and gradually improving them. The evaluation of medical quality is one of the core contents of hospital accreditation, and the quality of medical cases is an important content of medical quality. The case room according to the hospital's requirements of the first page of the medical record quality control, part of the physician to fill out the first page is easy to ignore, inaccurate understanding of the
Summary of the first half of the work of the Department of 7In this year's work, under the correct guidance of the leadership of the hospital, adhering to the work of the information for the scientific management of hospitals to serve the `Guiding Ideology, closely around the hospital for the development of the center, the full implementation of the duties and responsibilities, and highlighting the work of the comprehensive information for the hospital management services for the clinical front-line services. Hospital management services for the focus of clinical services, the successful completion of this year's information section of the work of the task. The first page of 309 cases of patients discharged from the hospital in the current year were coded for diseases and surgeries and uploaded to the Xuzhou Health Bureau.
In the work, keep the case room clean, neat, ventilated and dry. Recover, organize, bind, file and store the cases. Organize each discharged case, according to the requirements of the case writing specifications, according to the program to arrange, to ensure that the case is complete, not good binding, leakage of binding. Proficiency in ICD-10 coding, coding of the main diagnosis and name of the operation for each discharged case, microcomputer home page entry, bagging and filing. The staff of the hospital will be warmly received by the foreign case workers and the insured who need to make copies of the case information, and provide reliable information for the clinic in a timely and accurate manner.
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, I will continue to learn and use advanced case information management methods and computer knowledge, and strive to carry out new business, new technologies, and make greater contributions to the hospital's information work.
The first half of the work of the case department summary Part 8First, the daily management
The case room during the first half of the year, to complete the work plan in the end of the quality inspection of medical records, to complete the 12041 discharged medical records of the recovery, printing, organizing, quality control, ICD-10 coding review, filing, Shelving and supplying. Among them, 454 discharged cases were found in the final quality checking work***, which greatly reduced the filing rate of Class B cases, and the 7-day recovery rate of cases in all departments of the hospital has risen from 80% in December last year to 99% at present. In the case of the case room to ensure the smooth running of the daily work, the first half of the completion of 4149 copies of discharged medical records and more than 3,000 copies of discharged cases of quality control and access to work.
Second, statistics
The case room since March 20xx to receive the hospital workload statistics, do a good job of the hospital workload of the daily report, the monthly report review work, regular reporting monthly report, quarterly, do a good job of statistical analysis of the workload; very good will be the combination of the ICD code and the hospital's statistical work, for the hospital, the hospital outside the examination work to provide reliable data information access to information. The staff will be able to provide reliable data and information to the hospital.
Third, the construction of the case library
At present, the case library *** counts four, respectively, in the East Ward Building on the first floor, the second floor of the Comprehensive Building, the outpatient building on the fifth floor. Now the first floor of the storage room storage case more than 96,000 (full), the second floor of the storage room storage more than 130,000, which is occupied in the construction of the new building, the case has been boxed storage, to the application of the case has brought a greater cumbersome, now the fifth floor of the storage room storage of more than 60,700 copies of the medical records, storage space has reached a saturated state of the new wards of the building's application, the case room has been faced with the overall relocation of the work, the case of the storage room building urgently need to The hospital examined the placement of suitable location.
The first half of the work of the case summary Part 920xx year has been quietly away, 20xx year come, the case room is a comprehensive coordination, neutralization and service work. Review 20xx year case room work, the section staff in the hospital leadership and medical leadership of the correct leadership and strong support, always "patient-centered, to the core of the quality of medical care", now 20xx year case room work is summarized as follows:
First, the hospital's work indicators to complete
1, the hospital's total number of admissions: 14,461
2, the number of discharges: 14,439
3, the total number of annual outpatient visits: 150,615
4, bed occupancy rate: 83.9%
5, the average hospitalization day: 12.6 days
6, Number of bed turnover: 24.1 times
7, cure and improvement rate: 99.3%
8, diagnosis rate within 3 days of admission: 100%
9, Grade A medical record rate: 99.3%
10, healing rate of sterile surgical incision: 91.9%
11, infection rate of sterile surgical incision: 0.3%
12, critical, emergency and serious illnesses. 12, critical, emergency, serious patients accounted for the number of patients admitted:
13, critical patients resuscitation success rate: 96.6%
14, admission and discharge diagnosis compliance rate: 99.9%
15, pre- and post-surgery diagnosis compliance rate: 100%
Second, the medical record overdue archiving situation
90%), analyze the reasons for the following:
1, the idea is not enough to pay attention to, the physician in charge of the finishing in a timely manner, the quality control personnel quality control in a timely manner.
2, the transfer of patients involved in a number of departments, the original department staff signature is not timely.
3, the thought of reporting the theme of the superior physician signature is not timely.
Third, the preservation of medical records
1, the storage and retention of medical records in the case management work is an important work, medical records library is a key link in the protection of medical records. Because of the limited conditions of our hospital, the medical records warehouse is tense, under the existing conditions, the warehouse can keep clean, neat, dry, fire, heat, moisture, light, dust, insects, water. Recovered medical records can be organized, bound and filed in a timely manner to ensure the completeness of each medical record, and not to miss the installation. According to the International Classification of Diseases and Codes (ICD-10), the classification of surgical operations (ICD-9-CM-3) for each discharge medical records for disease classification code, the same patient has been hospitalized several times to achieve the unique case number.
2, has been filed in the medical records, such as the need to borrow, in the case of leaving the case room before the rules and regulations can be handled in accordance with the borrowing procedures, and urge the parties concerned to return in a timely manner. The return of medical records for verification, so that the rate of return of medical records, integrity of 100%. To come to the hospital to copy the medical records of the personnel can do warm reception, according to the relevant rules and regulations to strictly handle the relevant procedures, after the approval of the Medical Department to be copied.
Four, data statistics
Medical data statistics reflect the hospital's main workload, medical quality and efficiency, the patient's disease classification or distribution. The staff of the department can collect all kinds of data and information on time every day, regularly complete the daily, monthly and annual statistical work of all kinds of reports and data, and strive to achieve data integrity, accuracy and timeliness.
Fifth, medical ethics and labor discipline
The department staff can consciously abide by the rules and regulations of the hospital, and complete the work on time. In October this year, actively participate in the hospital organization "to improve the image of hospital services" activities. And according to the requirements of the work position to write the corresponding service commitment, developed a plan of activities, according to the plan again to organize the staff of the section for the "Hospital Management Manual" and "Hospital Employee Handbook" to learn, with reference to the handbook for self-correction, to strengthen the knowledge of the hospital's service process, and to strengthen the members of the section of the awareness of the independent service. Through the efforts of everyone in the hospital's "improve the image of service" assessment has achieved better results.
Six, the deficiencies of the department
1, the case room staff are not graduates of the case specialty personnel, in the classification of the disease coding or related statistics due to lack of professional knowledge, some of the disease classification coding, statistics, it is difficult to achieve 100% accuracy.
2, the lack of professional and technical titles, the case room staff is currently the case of professional primary technical title personnel only 2 people, holding a code skills level examination certificate of qualification 1 person, from the second A inspection standards are still a big gap.
3, the section of the individual staff work efficiency is not high, the work of the phenomenon of errors and omissions, the lack of enthusiasm for service, work less proactive, poor collaboration between colleagues.