Analysis of the quality of filling in the first page of the medical records of otolaryngology department of a tertiary public hospital
Objective:To investigate the status and influencing factors of filling quality of the first page of medical records in Otolaryngology department of a tertiary public hospital.Methods:1000 medical records from Otolaryngology department of a hospital from January 2018 to December 2022 were selected to evaluate the quality of medical records,and 856 qualified medical records were grouped according to the quality of medical records.144 unqualified medical records were included in the observation group.The clinical data of the two groups were compared,such as gender,age,education,professional title,length of hospital stay,and the influencing factors of medical record quality were analyzed by Logistic regression.Results:Among 1000 cases,856 were excellent,57 were good,42 were medium,31 were low,and 14 were poor.The defect rate was 14.4%(144/1000).The proportion of patients with age>50 years old and deputy chief physician in observation group was lower than that in control group,and the proportion of patients with hospital stay>10 days was higher than that in control group(P<0.05).Age,professional title and hospital stay were the factors influencing the quality of medical records(P<0.05).Conclusion:The quality of medical record filling still needs to be improved,which is affected by age,professional title,length of stay and so on.
OtolaryngologyQuality of medical recordsInvestigation of current situationInfluencing factor
NETL
NSTL
万方数据
维普
