Paper on Discipline Construction of Hospital Medical Record Management

The construction of key disciplines is a very important and strategic development task for the construction of general hospitals [1]. The discipline of medical record management is a relatively special discipline among the disciplines. It is a marginal discipline. Many data on the development and application of medicine come from medical records. However, most of the hospital's medical record rooms (departments) are not taken seriously by the hospital, the quality of the talent team is low, and the investment is insufficient. Due to various reasons, the level of medical record management is not optimistic. The development of the medical record room disciplines is slow, and some hospital medical record rooms are even shrinking. Phenomenon. With the advancement and development of science and technology, hospital management has become more scientific and medical research has become more extensive and in-depth. Medical record information management has also developed with the times. At the same time, it has also been deeply affected and impacted by modernization and informatization, regardless of concept. There have been significant changes in all aspects of technology and methods. During the development process, some conceptual errors led to misunderstandings in management, which seriously hindered the normal development of the profession and affected the hospital's investment in medical record information management. This made the discipline construction and development of the medical record room worse, and also affected the staff's performance. Positivity. How to build the discipline of medical record management in the medical record room under the new situation, develop it, and improve the status and enthusiasm of medical record managers. This is a question that managers must think deeply about, and it is also the direction for medical record managers to work hard. Facing the new situation, the medical record room of our hospital has made explorations and made great efforts in the construction of medical record management disciplines, and achieved certain results. We now provide medical record managers with reference.

1. The attention and support of leaders, the support of various departments, and the understanding and cooperation of medical staff are the first conditions.

1.1 The attention and support of leaders are the key to discipline construction and development. Prerequisites for development

Without the attention and support of hospital leaders, the construction and development of the medical record management discipline will be empty talk. The development of the hospital is inseparable from accurate medical record information. Medical record information can provide a large number of statistical analysis data sources for medical treatment, teaching, scientific research, epidemiology, health economics, etc.; attach importance to the development of the medical record room and medical record information, and integrate medical records into Organizing, mining, and statistical analysis of original data can provide strong data support for hospital management decisions, improve the hospital's management level, and enable the hospital to develop in an all-round way. Only when hospital leaders have these concepts can they pay attention to the discipline construction of the medical record room and give them the greatest support. At the same time, according to the requirements of medical record management, the medical record management departments of secondary hospitals should be directly under the leadership of the hospital president and vice president, and the subject leaders should be given the right to make decisions and suggestions, so that the discipline can develop rapidly. Over the years, successive leaders of our hospital have had a pioneering spirit and kept pace with the times. Coupled with our multi-party publicity, hospital leaders are fully aware of the importance of medical records to hospital management and development. In 2007, the medical records room was adjusted and set up as a business department of the hospital. , performs some functional department functions and is directly subordinate to the leadership of the Vice President of Business. Personnel with senior professional titles serve as department directors and have been approved by the Municipal Health Bureau. Hospital leaders have increased their support for the discipline construction of the medical record room and increased their investment in manpower and material resources. Over the past few years, they have invested millions of dollars in the development of the medical record room, making our medical record room more advanced in terms of hardware and software. We have moved up a floor and implemented modern management.

1.2 The support of various departments is a force that cannot be ignored in the construction and development of the discipline.

Whether the equipment in the medical record room is advanced and complete is the material guarantee for the construction of the medical record management discipline. In addition to traditional medical records In addition to office supplies such as racks, dense medical record racks, tables and chairs, with the application of modern technology in medical record information management, its material support also includes a large number of electronic equipment such as computers, printers, barcode machines, disks, digital copy machines, and fax machines. etc., all of which are inseparable from the support of the hospital's material support department, computer center, and property department; the talent training in the medical record room and further study abroad are inseparable from the support of the medical department and teaching department; the introduction and investment of talents are inseparable. HR department support and more. Therefore, support from various departments is a force that cannot be ignored in discipline construction. As the director of the medical record room, he should constantly improve his management level, innovation awareness and coordination ability in all aspects; medical record managers should also improve their interpersonal relationships with personnel in various departments. With the attention of hospital leaders and the support of various departments, the medical record room of our hospital is currently equipped with computers, printers, barcode printers, packers, punchers, scanners, copiers, compact racks, dehumidifiers, air conditioners, and thermohygrometers wait. Over the past 6 years, we have recruited 3 graduates of clinical majors and 5 undergraduates; more than 30 people have been sent to participate in various training exchanges at home and abroad; this has provided material and talent support for the discipline construction and development of our department. Assure.

1.3 The understanding and cooperation of medical staff are favorable conditions for discipline construction and development

To make medical staff aware of the importance of medical record management, the work done by medical record managers is not simply The archived medical records are organized, bound and put on the shelves. Instead, the archived medical records are carefully organized, sorted, bound, entered, coded, checked, and final quality controlled and put on the shelves according to the requirements of medical record management. The entire medical record management process is rigorous. ;Medical record management is a profession like clinical medicine; the quality of medical record management will affect the quality of medical care, prevention of medical disputes, scientific research management, scientific utilization, teaching quality, etc.

Efforts will be made through publicity and practical work to allow medical staff to understand and cooperate with medical record management and create favorable conditions for the discipline construction and development of the medical record room. We publicize the importance of medical record management through various occasions, often provide feedback on quality problems in medical records written by medical staff, and provide them with rectification opinions and suggestions. We have eliminated Class C medical records and greatly reduced Class B medical records, improving the quality of each department. The high Grade A rate of medical records enables clinical departments and medical staff to reduce economic losses and other penalties, and ensures that their medical records pass various inspections by superiors. The development of the medical record room has provided clinical medical staff with various information materials, which has brought their medical treatment, scientific research, teaching and other levels to a higher level, allowing them to use medical record information more quickly and conveniently; at the same time, supplemented by medical records Manage the implementation of the reward and punishment system to improve their compliance with medical record management. Through the benefits that these practical tasks bring to medical staff and the constraints of the system, medical staff can truly understand the importance of medical record management, enable them to understand and actively cooperate with the work of the medical record room, and the discipline construction and development of the medical record room can be achieved. Smoother.

2. Clarify the discipline development plan

The discipline plan is the blueprint and basis for discipline construction. Condensate, clarify and grasp the main direction of hospital disciplines, and develop advantages and characteristic disciplines with unique capabilities. Condensing the subject direction is the key to subject construction. We should base ourselves on the local area, follow the example of advanced peers across the country, and formulate construction plans and plans that are in line with the development of this discipline based on the actual conditions of our unit. We should clarify the purpose, direction and project areas of discipline construction, and formulate plans for talent training, scientific research, and academic echelon building. wait. Based on the current medical record management status of our hospital and the local municipal and provincial hospitals, as well as many domestic third-level A-level hospitals, as well as the development level of this professional discipline, we have formulated a three-year and five-year discipline development plan and gradually implemented it. First, we analyze the current situation of our hospital, including talent quality, team building, working conditions, subject management, scientific research, etc., discover weak links, take targeted measures, and continuously improve, achieving the transformation from traditional management to modern management. The transformation has brought the departments of our hospital to the forefront of the province.

3. The construction of disciplines must establish rules and regulations to form a set of efficient operating mechanisms

Without rules, there will be no success. Only by establishing rules and regulations can an efficient operating mechanism be formed to ensure that the construction of disciplines develops towards the established goals. Let medical record management personnel clarify the purpose, goals, responsibilities, responsibilities, standards for task completion, and reward and punishment measures, so that they can complete their tasks in a united and cooperative manner while maintaining quality and quantity, while mobilizing their enthusiasm for work and stimulating their enthusiasm for work. Let all members of the discipline work together to build the discipline. We have formulated work quality standards, design processes, and implementation steps for each position, work characteristics and details of the medical record management process in accordance with the relevant regulations on medical record management and the evaluation standards of tertiary general hospitals; they are divided by positions and professional groups. The quality unit sets the position staffing according to different workloads and professional titles, and divides the areas of responsibility. Various systems, responsibilities, plans, rewards and punishments have been formulated and strictly implemented. The department has also set up a quality control team to conduct self-inspections and mutual inspections on the quality of work on a daily basis to inspect the quality of each link every month. If problems are found, rectifications will be required and penalties will be imposed; for timely discovery of problems, correction of other people's mistakes, and acceptance by the hospital and patients The commenders were given rewards to mobilize the enthusiasm of the staff, and achieved interlocking, mutual help, layer-by-level checks, rewards and punishments, and individual responsibilities. The work was constantly explored and improved to ensure the smooth development of the discipline.

4. Discipline construction and development of talents are the key

4.1. Discipline leaders are the key factors that determine the level, characteristics and advantages of the disciplines.

Discipline leaders must have high Academic qualifications, profound knowledge, exquisite professional skills, good management capabilities and noble medical ethics. At the same time, the director of the medical record office should be able to study hard, grasp the development trends of health information management at home and abroad, be extremely responsible for work and career; constantly explore the management of the department, establish efficient and effective medical record services, and be good at doing a good job in the medical record department Plan; organize work reasonably and effectively; make full use of and develop human resources; guide staff correctly and master, control and coordinate the work between departments. The director of the medical records office should have at least a professional title of associate senior or above, and be dedicated to medical record management. Only in this way can he grasp the development direction of the discipline, have a greater sense of responsibility and mission, and have both duties and powers, so that discipline construction can achieve better development. Subject leaders are different from academic leaders. Discipline leaders must be able to grasp the development direction of the discipline, formulate discipline construction plans, determine discipline construction goals and major scientific research projects, grasp the overall situation, and actively tap the radiating effect of discipline construction benefits. The director of the medical records office of our hospital strives to follow the discipline requirements required by the dean. Nine elements for a leader to do: have a sense of professionalism, responsibility, and dedication; have a sense of innovation and development; have high emotional intelligence and a spirit of unity and cooperation, be patient and willing to suffer losses, and be able to do as many things as you can in your heart. ; You must have the ability to drive the development of professional medical standards; you must have an economic management mind; you must have the quality and quantity of scientific research; you must be a role model and teach others; you must have the ability to prevent and control medical risks; you must have rapid execution.

The director of the medical record office pays attention to the construction of medical record management culture, constantly enhances the attraction, cohesion and appeal of this culture, effectively improves the comprehensive quality of medical record staff, and has made a five-year plan for discipline development and a talent training plan to transform the original medical record office The traditional management model has gradually been transformed into a modern management model, making our department the leading unit in the city's medical record management professional discipline and the affiliated unit of the municipal medical record management professional quality control center. The director of the medical record office has become the director of the municipal medical record management professional quality control center and the municipal medical record management professional quality control center. Leader of the Disease Operation Code Expert Group; Chairman of the Medical Record Management Professional Committee of the Haixi Medical and Health Development Center of the National Secondary Association.

4.2 The construction and development of disciplines are inseparable from a high-quality talent team

A high-quality, technically competent talent team is the main force in completing discipline construction. Medical record management involves multidisciplinary knowledge and skills and is a highly professional subject. Medical record managers must not only master certain clinical medicine, basic medical knowledge, hospital management, and information technology management, but also must be proficient in disease management. Classification, surgical operation classification, computers, statistics, medical record management expertise and other knowledge, especially the development of information technology, require medical record managers to have high computer application capabilities; talents should form an echelon in the construction of disciplines. Only by building professional platforms at different levels for all types of talents through "academic further study, special training, international cooperation, conference exchanges, visits" and other methods can we build a main force for discipline construction with a team of high-quality and technically competent talents. At present, due to management system and historical reasons, and some leaders not paying enough attention to medical record management, many hospitals in China have arranged some personnel who have retired from clinical positions to the medical record room, resulting in a shortage of medical record professionals among the current medical record room staff. , unreasonable cultural levels, misplaced talents and professions, aging personnel and other phenomena; at the same time, no attention is paid to the training of medical record room personnel, resulting in stagnant development of the medical record management profession. Our hospital also had some problems in the past. In response to these problems, with the attention of hospital leaders, we established and improved a working model for cultivating and introducing talents.

4.2.1 Introduce talents and cultivate subject leaders. The selection and training of reserve candidates for subject construction must have a good talent echelon, and it is crucial to strengthen the cultivation and introduction of subject talents. In response to the problem of low academic qualifications, in the past five years, our quality control team has recruited two medical clinical graduates, and the coding team has recruited three undergraduates in hospital information management-related majors to improve the cultural level of our department and change the phenomenon of aging personnel. . Discipline construction should attach great importance to strengthening the selection and training of reserve candidates for subject leaders. Establish an outstanding talent reserve, implement targeted tracking training, and cultivate a reserve army of subject talents. For new graduate students and undergraduates, we actively provide them with necessary work and study guarantees by assigning tasks, shouldering responsibilities, and encouraging them to continue to learn, improve, and improve; at the same time, we cultivate their good professional ethics and strong Organizational management skills, strong sense of responsibility and career pursuit. They have become the backbone of our discipline construction.

4.2.2 Job-based training Since most of the staff in our department have transferred from other majors, they lack systematic and standardized medical record management knowledge and skills. In this regard, we adopt the method of passing on, helping and guiding, so that personnel who have received medical record management knowledge and skills training will provide them with regular or irregular training; each new employee must rotate in each position for 2 years and will be approved after passing the assessment. On-the-job; It is stipulated that every person who goes out for further study and exchange should report and convey it after returning to the department; when encountering problems during daily work, department staff will discuss and communicate with clinicians to achieve the purpose of mutual improvement.

4.2.3 Increase the opportunities for medical record management personnel to go out for further study and training, strengthen communication with the outside world, and formulate personnel training plans. Combined with the needs of discipline construction, expertise and job requirements, targeted education and training of personnel , sending personnel to participate in professional further education, training, and learning exchanges at home and abroad. Personnel with junior professional titles will go out for study and exchange 1 to 2 times every three years, and personnel with intermediate professional titles and above will go out for study and training 1 to 2 times a year. In the past five years, *** has sent 1 person to study abroad, 2 people to study domestically, and 33 people to participate in learning and training exchanges. This has enabled department staff to broaden their horizons, accept new knowledge and information, and improve the professional level of medical record management.

4.2.4 Strengthen the cultivation of personnel’s professional quality and improve their professional level. Over the years, our department has undertaken the teaching task of the medical record management theory course of the health information management major of a college in Xiamen City, and dispatched intermediate Personnel with professional titles or above and who have received professional training give lectures, and they also teach interns and trainees from major and vocational colleges. Through teaching and teaching, the personnel review their professional knowledge and improve their skills. The teaching level of the staff. Department staff, especially those with intermediate professional titles and above, are required to publish an academic paper at or above the provincial level every year, and graduate students should try to have scientific research projects at or above the municipal level. In the past five years, the general practice has published 10 papers in academic journals at or above the provincial level. By writing papers, the scientific research capabilities of department staff have been cultivated, and they have also learned about the development trends of domestic and foreign disciplines. The core of discipline construction is talents. Professional knowledge, teaching and scientific research capabilities are essential elements for discipline construction and development. All-round development is the direction of efforts.

5. Refinement and the adoption of modern management methods are the foundation and direction of discipline construction and development

The development of disciplines does not only depend on personnel, comparative advantages, business prospects, and the objectiveness of the unit. Conditions and relevant policies and systems, we must also pay close attention to the situation of surrounding units and predict future development trends; therefore, the development of the discipline should be fully assessed, forward-looking, and scientifically planned. With the rapid development of informatization, the medical record management profession is facing challenges. The traditional management model no longer adapts to the needs of the new situation. The management model must be transformed from refined and modern management in order to move towards the advanced level of discipline construction. Only through the refinement of management can medical record management personnel be refined, quality guaranteed, and efficiency improved. Only by adopting modern management methods can work be more efficient, data be more accurate, and medical record data be applied more conveniently and extensively.

5.1 Refinement of management

In the field of hospital management, it is known that "the hospital has advantages, the department has characteristics, and the people have expertise". Create a discipline brand and form a strong Advantages and featured technologies are the key. In order to make our discipline construction have unique characteristics, respond to the challenges of the internal and external environment, enhance the motivation for discipline development, and improve the core competitiveness of this discipline, we have taken the following measures.

5.1.1 Professional refinement Based on the different job responsibilities, detailed rules, personnel qualities and specialties of each position, we implement fixed positions and fixed staffing. Everyone is engaged in a fixed professional development direction to make their profession more specialized and refined. , sharp development.

5.1.2 Refinement of systems, responsibilities, processes, and safety measures Successful discipline construction is inseparable from a scientific mandatory system. The construction of the compulsory system includes the construction of organizational structures, rules and regulations, etc. Organizational structure is the dynamic structural system of an organization in terms of duties, responsibilities, and rights. Its essence is a division of labor and collaboration system adopted to achieve the strategic goals of the organization. To this end, we have developed corresponding systems, responsibilities, and safety management based on each link, process, and nature of medical record management, including the recovery, sorting, sorting, binding, coding, quality control, digital processing, archiving, and storage of medical records. Measures have been taken to refine each medical record and process, assign responsibilities to each person, and link them to their performance appraisals, thus improving the quality of medical record management.

5.2 Modernization of management methods

5.2.1 Use common management tools for management We use seven major management tools for quality management in each link, which are: checklist, level Methods, Plato, cause and effect diagrams, scatter diagrams, histograms, and control charts are used to collect and analyze quality data in each link, analyze and determine quality problems, and control and improve quality levels.

5.2.2 Adopt modern technology and equipment for management. Use barcode tracking and positioning system management. Based on the medical record number, department, discharge date and other information, use barcode production software to prepare barcode symbols, print them and affix them On the cover of the archived medical record; scan it with a barcode reader, and the patient's information will be displayed on the computer screen; it can be applied to all aspects and positions of medical record management to facilitate information inquiry and positioning of medical records. Apply electronic medical record data to realize online application and online return of electronic medical records, and establish various levels and various permissions to facilitate medical staff to review and modify; at the same time, it is convenient for the medical record room to monitor the final quality online and collect data for statistics and reporting. Medical data required by the Ministry of Health. Digital medical record management technology is used to digitize archived medical records, so that all users can combine and fuzzy customized queries through the medical record homepage and other contents in the medical records, and can perform excerpts, analysis and statistics within the system, and export documents for application; It has extensive, accurate, fast retrieval and statistical performance, true image recording, good enjoyment, saves users a lot of time, takes up little space, saves medical record storage space, and has the advantages of low cost, which meets the needs of our hospital. The demand for the use of medical records in many aspects such as medical treatment, teaching, scientific research, management, etc. has certain standardization, safety, practicality and advanced nature. The intermediate color code coding method is used to paste the medical record number in different colors on the cover of the medical record, and the medical record numbers are distinguished by color, so that medical records personnel can easily identify the medical record number and avoid filing errors. The application of the above modern technologies and equipment has transformed the management of our department from a traditional management model to a modern management model, improved work quality, work efficiency and accuracy, achieved comprehensive, multi-functional, all-round high-quality services, and provided scientific decision-making and prediction for the hospital. Provided important basis.

6 Strengthen team building and provide an incentive mechanism that keeps pace with the times

A team refers to a group of people who help each other, are united, and work hard to achieve unified goals and standards. . The team not only emphasizes individual results, but also emphasizes the overall performance of the team. The team is based on collective discussion, research and decision-making as well as information sharing and standard strengthening. It emphasizes that the fruits of victory are obtained through the efforts of members, and these fruits exceed the sum of individual performance. We require members of the department to unite, understand and trust each other, to brainstorm and work together. Under this premise, we gave full play to the advantages of the team and mobilized the enthusiasm of different types of talents. Only when talents are constantly stimulated can they continue to innovate and improve, and can they maximize their potential and contribute to collective goals. It is very necessary to establish an incentive mechanism that can mobilize the enthusiasm of all personnel.

In addition to the incentives for department staff in accordance with hospital regulations, we have also developed a series of department reward mechanisms, such as: rewards for paper publication, scientific research results, and academic improvement; Priority for meetings, training, study tours, promotions, etc.; rewards based on work performance and praise from all parties; fairness, justice, openness and reasonableness are reflected in remuneration. Mobilized the enthusiasm and initiative of our department staff. After several years of exploration in subject construction, the medical record room of our hospital has gained the above practical experience, which is only for reference by peers. We still have many problems in discipline construction, and we will continue to explore and continuously improve our work in order to improve the level of discipline construction, establish a discipline with great social influence, and strive to maintain the core competition of advancing with the times in a fiercely competitive environment. Strength, win a double harvest of two benefits.

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