The Impact of Logical Check and Coding Quality Control Review on the Quality of Filling in the First Page of Inpatient Medical Records in Traditional Chinese Medicine
Objective:Analyze the impact of logical validation rules and coding quality control audits on the quality of filling in the first page of inpatient medical records in traditional Chinese medicine,providing a reference for improving the quality of the first page of traditional Chinese medical records.Methods:Using 21,779 inpatient medical records from a certain integrated hinese-Western medicine hospital in 2022 as the control group,and 24,574 inpatient medical records from 2023 as the observation group,set up logi-cal validation based on the requirements of the first page of traditional Chinese medical records,and conduct quality control on coding,comparing and analyzing the differences between the two groups.Results:The control group had a total of 21,779 medical records,with 3,738 cases of defects;the observation group had a total of 24,574 medical records,with 1,818 cases of defects.After logical vali-dation,the defect rate of the inpatient medical record first page decreased from 17.16% to 7.40% .According to the chi-square test,P<0.001,indicating a significant difference in the defect situation,and the systematic logical validation had a significant effect.Conclu-sion:Using a pre-logic verification program to verify the content of the inpatient medical record first page can effectively improve the accuracy and completeness of filling in the medical record first page,reduce labor costs,improve work efficiency,and have a positive impact on improving the quality of medical data.
Logical VerificationFirst Page of Chinese Medicine Hospitalization Medical RecordsQuality Control
万方数据
维普
