Analysis of the application effectiveness of the inpatient medical record front page quality control sys-tem from the perspective of high-quality development
Objective To explore the application effectiveness of the combined intelligent quality control and manual quality control system for inpatient medical record front pages,and to analyze the reasons for defects in filling out the front page of inpatient medical records and improvement measures.Methods Using the time when the intelligent medical record front page quality control system went online as the node,we selected inpatient medical records from January 1,2022,to June 30,2022,as the control group,and inpatient medical records from January 1,2023,to June 30,2023,as the observation group.We com-pared and analyzed the situation of defects in filling out the front page of inpatient medical records between the two groups.Re-sults Defects in filling out the front page of inpatient medical records were divided into 17 categories.By establishing the inpa-tient medical record front page quality control system,the overall defect rate of filling out the front page of inpatient medical re-cords in the observation group(4.76％)decreased by 6.87 percentage points compared to the control group(11.63％),and the defect rates of various categories decreased to varying degrees.According to the descending order of the decrease in defect rate of front page filling,the top three defect categories with significant decreases were omitted surgeries and procedures,incorrect selec-tion of primary diagnoses,and omitted other diagnoses.The differences in statistical data were statistically significant(P＜0.05)based on the x2 test.Conclusion The combination of an intelligent quality control system and manual quality control system can significantly improve the quality of inpatient medical record front pages.However,it is still necessary to strengthen training in clinical departments,performance assessment of inpatient medical record front pages,and information construction to continuously ensure the sustained upward spiral of the quality of inpatient medical record front pages and promote the high-quality and sustain-able development of public hospitals.
High-quality developmentFront pages of inpatient medical recordsQuality controlQuality control system
维普
万方数据
