Personal summary of medical record room

Summary is a written material that comprehensively and systematically reviews and analyzes the study, work or its completion in a period. It plays a connecting role in our study and work, so it is better to calm down and write a summary. How should I write a summary? The following is my personal summary of the careful arrangement of the medical record room, for reference only, hoping to help everyone.

Personal summary of medical record room 1 Medical record room is a comprehensive, coordinated and neutral service. A qualified medical record room staff has strong political quality and professional ability, rigorous and capable work style and hard-working spirit, because they have strong professionalism, high sense of responsibility and pragmatic work attitude. I always believe that as long as I work hard and take it seriously, I will be recognized.

When I entered the hospital, my important task was to be familiar with the working environment, learn the computer case input system, cooperate with the leaders to copy and distribute the information of various departments in time, and notify the unfinished cases in time. I always practice the working concept of serving the leaders, departments and patients well, conscientiously complete all the work arranged by the leaders, cooperate with the leaders to successfully complete the work tasks, cultivate comprehensive quality and improve work ability. Don't let the work arranged by the leaders be delayed in your own hands, don't let the matters handled accumulate in your own hands, don't let all kinds of mistakes happen to you, and don't let the patients who copy medical records be left out in the cold here, so as to cultivate service consciousness. Accurately understand the important role of medical record management, enhance the understanding of the modernization of medical record management, and report the medical records encountered in litigation to the leaders in time. Always keep a clear political mind, put yourself in a correct position, and try to arrange your work in an orderly way. When it came, I studied hard in this mood. Put the enthusiasm for the cause and a highly serious and responsible attitude into the work, resolutely obey the leadership and serve the patients. Consciously abide by the rules and regulations of the hospital and labor discipline, and meet the needs of patients to the maximum extent.

I like and cherish this position very much. It is not only a melting pot, but also a stage, which can not only exercise itself, but also show itself in the debriefing report of Secretary 20xx. Looking back on my work during this period, I have basically completed my job, which is inseparable from the support of my leaders and the help of my colleagues. I would like to express my heartfelt thanks to all the leaders and colleagues! The above is a summary of my thoughts and work in the past six months. Please criticize and correct the incomplete and inaccurate places. In my future work, I will make a personal work plan to make my work better. Live up to the expectations of the leaders. On June 6th, 20xx, I came to work in the people's court. At the beginning, for me without any work experience, faced with such a job, my mood was complicated and my heart was under great pressure. But I think this is also experienced and honed for a fledgling graduate like me, so I embarked on this unforgettable journey with confidence.

In practical work, through unremitting efforts, the concern of leaders and the enthusiastic help of colleagues, I gradually integrated into the big family of People's Hospital. Here I learned the truth of being a man and how to deal with people. I strictly abide by the rules and regulations of the hospital, earnestly perform my duties as an intern nurse, be strict with myself, never arrive late and leave early without reason, work steadily, and actively participate in various activities organized by the hospital on time.

The medical record room is a comprehensive work, a coordinated and service work. An excellent medical staff in the medical record room should not only have a strong sense of professionalism, a high sense of responsibility and a pragmatic work attitude, but also have excellent political quality and technical level, rigorous and meticulous work style and hard-working dedication. But I always believe that as long as I work hard and take every task seriously, I will be recognized by leaders, colleagues and patients.

My first task when I entered the hospital was to get familiar with the working environment, learn the computer case input system, cooperate with the leaders to copy and distribute the information of various departments in time, and notify the unfinished cases in time. I have been practicing serving the leaders, departments and patients well.

Personal summary of the medical record room 2 Summary of the statistical work of hospital medical records Since the reform and opening up, China's national economy has grown rapidly year after year, and the pace of hospital modernization has also developed rapidly. Medical records and statistical work, which can show the process of hospital modernization, not only serve medical treatment, teaching, scientific research and management, but also show the change degree of hospital modern technology, advanced instruments and equipment and service attitude with data.

The medical records and statistical data of China hospitals have changed greatly in recent ten years, and the speed of change is unimaginable for ordinary people. In many aspects, it has been in line with international standards, and many hospitals are about to keep pace with the developed countries in the world. Specific performance:

First, in the past, medical record business card printing, registration, statistical tabulation were all manual operations, and now computers have been used.

(1) Classification of previous diseases, classification of internal (surgical) operations, name, doctor and follow-up index card; The pathological examination of inpatients, dead patients and corpses has a register, which is all manually operated. At present, most hospitals have computers in outpatient registration rooms, inpatient departments, wards and medical record statistics departments (rooms). These departments work together, and carefully input the "medical record home page" into the computer as required, which can bring up various index cards and various registration items. The statistical report data of "Hospital Inpatients' Disease Classification" submitted by the health administrative department can also be transferred from the computer as required.

(II) In the past, the daily number of inpatients in and out of the hospital (including death, the same below) was reported by various clinical departments, and the "discharged patient card" (summarized on the first page of medical records) was also reported as the basis for discharged patients, and the daily number of inpatients in and out of the hospital on the previous working day was summarized and submitted to hospital leaders and relevant departments. Now, as long as the clinical department inputs the number of patients entering and leaving the hospital in the previous working day into the computer, the medical record statistics room can call up the "Daily Report of Inpatients". Hospital leaders and relevant departments can also call out from the computer, and the data is accurate, unified and fast.

Daily newspapers stored in the computer are accumulated over time, and daily, monthly, quarterly, semi-annual and annual reports stipulated by the health administrative department or required by hospital leaders can be compiled.

Second, in the past, the arrangement of hospital medical records was generally arranged in the order of hospital medical records. This method is easy to find medical records, and it is more troublesome to return them. Once they are misplaced, they will be hard to find next time. At present, some hospitals, such as Sheikh and 30 1, have adopted the "tail number shelving method" to find the reverse order, which is very convenient, not easy to misplace, and can improve the work efficiency several times, and should be vigorously promoted.

Third, medical record preservation. According to Article 35 of the Regulations on the Administration of Medical Institutions promulgated by Order No.35 of the Ministry of Health on August 29th, 1994/KLOC-0, the storage period of outpatient medical records in medical institutions shall not be less than 20xx years; The retention period of hospital medical records shall not be less than 30 years. Calculated by 30 years: In a hospital with 1 0,000 beds, the average length of stay for patients is 1.3 days, and the number of beds is 26 times a year, with an average of about 26,000 people discharged each year. 780,000 medical records should be preserved in 30 years. Generally, every 10,000 medical records occupy about 5㎡ of the medical record database, and a total of 390㎡ of the medical record database is needed, with a total construction area of 585㎡. According to the protection requirements of the construction of medical record library, the cost per ㎡ is about 4,000 yuan (national average), of which the domestic investment of medical record rack is 2.5-3 million yuan.

If only 20xx medical records are stored every year, and 520,000 medical records in the first 20xx years are stored on microfilm or CD-ROM, 390㎡ medical record database can be built less, and the construction investment can be reduced by 1.60 ~ 1.90 million yuan. Saving half the investment can solve the problem of purchasing microfilm or CD-ROM equipment and making microfilm or CD-ROM medical records. It is superior to the medical record database in the following features:

(1) The medical records stored on microfilm or CD-ROM will be 30 years from 20xx to 20xx. By analogy, the medical records stored in microfilm or CD-ROM are increasing year by year, which actually increases the priceless medical resources used in medical teaching and scientific research.

(2) Microfilms or CDs stored in special filing cabinets can achieve "five precautions" and are safer than medical record racks.

(3) Using microfilm or CD-ROM to store medical records is the trend of all countries in the world, and it is the symbol of the modernization of medical record management.

(4) With the development of science, the prices of microforms, CDs and other products are gradually decreasing, and the investment will also be gradually reduced, which can also reduce the labor intensity.

Four, in the past, the hospital information department set up medical records, statistics, books and computers, which originated in the 1980s.

The national academic conference on medical record statistics was held in Nanjing, and the requirements for medical record statistics in medical institutions and the measures for classified management of hospitals of the Ministry of Health were drafted. In 1990s, hospital medical records (including statistics) in developed countries developed into information institutions, and computers were the tools of information (medical records statistics). Due to frequent international academic exchanges, some hospitals in Beijing, Tianjin, Yangtze River Delta, Pearl River Delta and other regions with rapid domestic economic development have merged statistics into medical records (different from the merger of medical records statistics). The professional committee of medical record management of China Hospital Association has compiled corresponding software, and medical records and statistics can be transferred from the computer. Medical records, statistical work and institutions will be combined with the use of computers.

After the merger of medical records and statistical institutions, the medical record room should be called the medical record information room.

A reform that saves manpower, saves time and improves work efficiency is a concrete manifestation of the implementation of Scientific Outlook on Development.

5. Medical record statistics play a leading role in hospital management. When the statistics of medical record management are done well, hospital management will develop to a higher level and gradually standardize. With the merging of hospital medical record statistics, medical records can be well written (which requires the efforts of doctors), managed and used, and the first page of medical records can be input into the computer, and the necessary medical statistical indicators can be output for hospital management reference. Medical record statistics have been institutionalized, standardized and programmed.

This is the result of studying and implementing Scientific Outlook on Development and taking the road of Socialism with Chinese characteristics (medical records in western countries are set up separately in hospitals). This achievement needs to be studied, summarized and concluded by professionals with knowledge and experience in hospital medical record statistics and hospital management. This is an innovation, which will not only change the status quo of hospital medical record statistics and hospital management, but also have an impact on hospital management throughout the country.

Personal Summary of Medical Record Room 3 In order to strengthen the connotation construction of medical records in our hospital, improve the quality of medical records, ensure medical safety, and make our doctors adapt to the new medical records faster and better, according to the requirements of the Basic Specification for Medical Records Writing, our hospital organized our doctors to train in the Basic Specification for Medical Records Writing in batches in the second half of 20xx. This year, residents took turns to train in the medical record room and made a careful study plan. The importance and necessity of standardizing medical record writing are reiterated, and the relevant laws and regulations, medical record writing norms, hospital medical record quality grading standards, international disease ICD- 10 classification, international surgical ICD-9 classification, and the instructions for filling the first page of medical records are studied.

Under the guidance of medical record quality control, participate in the final quality inspection of archived medical records, check the defects and problems in medical record writing according to the quality evaluation standard of inpatient medical records, analyze the causes of medical record defects, put forward rectification suggestions and basis, and timely feedback the situation to urge clinicians to improve in time. In practice, students personally feel the heavy and pressure of medical record quality inspection, and discuss how to avoid these defects and better strengthen the connotation quality of medical records.

In the process of training, students have mastered the basic contents and requirements of medical record writing, such as: standardized filling of the first page of medical record, incorrect filling, standardized writing of hospitalization record, standardized writing of first admission record format, standardized writing of content, key points of three-level ward round record, etc., which enriched doctors' professional knowledge and promoted the transformation of medical record from format quality to connotation quality.

Understand the legal effect of medical-related laws, regulations and medical records, strictly enforce medical behavior, improve medical quality, and promote the relationship and coordination between doctors and patients. Strengthening the awareness of medical record quality and improving the awareness of law at the same time plays an important role in improving the quality of medical records in our hospital. Through this year's study, residents have been promoted to straighten out the relationship between medical record writing quality and medical quality, establish good writing habits and sense of responsibility, and fully realize the importance of medical record writing. Through this year's study, residents have been promoted to realize the responsibility of clinicians for medical records, and they must write medical records objectively, truly, accurately, timely, completely and standardly with a high sense of responsibility and a serious and responsible attitude. Put an end to disputes caused by medical record writing problems and establish a good image of the medical industry.

Through the training of residents, doctors can learn ICD- 10 and ICD-9, understand the necessity of scientific and accurate disease naming and writing, and understand the external causes of injury and poisoning, so as to make epidemiological analysis of factors affecting human health. By understanding and mastering the basic knowledge of these medical marginal departments, the habit of irregular writing of disease diagnosis has been changed and corrected, and the basic literacy and professional skills of clinicians have been improved At the same time, the training has established a good communication relationship with clinicians, which is conducive to better learning from each other in the final examination of medical records in the future, better discussing and consulting with clinicians when there are problems, better solving practical problems encountered in the writing of clinical medical records, and improving the professional ability of medical record room staff.

Through the practice of inputting the first page of medical records by computer, residents learned how to make full use of the rich information resources in the statistical system of hospital medical records, which also promoted the data design, retrieval and extraction of clinical medical papers and scientific research topics in the future and improved the ability of clinicians to comprehensively use information resources.

Through this training, the residents in our hospital have a more in-depth and detailed understanding and mastery of the Basic Specification for Medical Record Writing, which has improved the quality and learning enthusiasm of all staff in the medical record room. Doing a good job of practical training in inpatient medical record room is particularly important for the continuous improvement of medical record quality in our hospital. In the future work, we will, as always, make unremitting efforts to do a good job in training the inpatient medical record room!