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《Chinese Medical Record》 2012-05
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The Reasons and Countermeasures of Delayed Filing of Medical Records

Wang Xiulian,Department of Medical Records,Qinglong Man Minority Autonomous County Hospital,Qinhuangdao 066500,Hebei Province,China  
Medical records filing is a key and difficult point in medical records work.For a long time,delayed filing of medical records generally exists that seriously affect timely statistic and effective application of medical records information,bring unnecessary passive even medical tangle for hospital and medical records staffs.Through observation of medical records filing situation from 2010 to 2011 in our hospital and statistical analysis of medical records filing rate of two typical departments,this article summarizes the reasons of delayed filing.From the aspect of medical records staffs,it is lack of management force;from the aspect of clinical department,it exists problems such as objective factors of clinical work,being lack of value on medical records of doctors;delayed accomplishment of complex medical records;non-standard and incomplete writing of medical records,which leads to delayed filing.Hospital should pay attention to and strengthen medical records filing and establish effective filing process and punishment and reward system that makes medical records information resource are effectively applied.Finally,this paper puts forward a series of solution countermeasures.Through operation practice,it gets better achievement,effectively decreasing delayed filing rate of medical records and increasing filing efficiency.
【CateGory Index】: R197.3
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