Investigation of the quality of outpatient medical records in 5 military hospitals from 2021 to 2022
Objective To explore the quality of outpatient medical records of 5 military hospitals from 2021 to 2022,so as to improve the writing quality of outpatient medical records.Methods A total of 358 outpatient medical records of 5 military hospitals from 2021 to 2022 were sampled and evaluated based on the supervision standards of outpatient medical records of the corresponding hospitals.The reliability coefficient of the standard was 0.417,KMO value was 0.6,and the significance of Bartlett's sphericity test was less than 0.05.Results The qualified rate of 358 outpatient records of 5 military hospitals from 2021 to 2022 was 81.56％.The qualified rate of outpatient records was 94.12％in the departments of medical specialties,which was significantly higher than that of the departments of surgery and internal medicine(84.35％,74.86％,P<0.05).The defect items of medical records were mainly past history,current medical history,treatment and auxiliary examination.The defect rates of past history and physician signature in outpatient medical records of level Ⅱ hospitals were 33.56％and 8.90％,respectively,which were significantly higher than those of level Ⅲ hospitals(19.81％,3.77％,P<0.05).The defect rates of auxiliary examination and physical examination in outpatient medical records of level Ⅲ hospitals were16.51％and 14.62％,respectively,which were significantly higher than those of level Ⅱ hospitals(8.22％,6.16％,P<0.05).The defect rates of past history and general items in outpatient records of the department of surgery were 37.39％and 16.52％,respectively,which were significantly higher than those of other departments(P<0.05).The defect rates of current medical history,chief complaint and auxiliary examination in outpatient records of the departments of medical specialties were 36.76％,23.53％,and 25.00％,respectively,which were significantly higher than those of other departments(P<0.05).The defect rates of physical examination and diagnosis in outpatient records of the department of internal medicine were 14.86％and 12.00％,which were significantly higher than those of other departments(P<0.05).Conclusion The overall quality of outpatient medical records is good in 5 military hospitals from 2021 to 2022,but there are some writing defects.It is essential to strengthen the writing training and quality control of outpatient medical records,so as to continuously deepen the quality management of outpatient medical records.
Military hospitalOutpatient medical recordsQuality analysis
万方数据
维普
