Objective Take the reform of medical insurance payment as an opportunity to strengthen training,improve the medical records management and quality control system of traditional Chinese medicine(TCM),and formulate the evaluation mechanism,in order to improve the connotation of medical records and the quality of first page data.Methods Before and after the revision of the three-level quality control system and quality control assessment system of medical records in our hospital in October 2023,200 medical records from July 1,2023 to September 30,2023 were randomly selected as the control group,and another 200 medical records from January 1,2024 to March 31,2024 were randomly selected as the experimental group.Statistically tested the rate(％)of grade A medical records in the two groups.Results There was statistical significance between the two groups(P＜0.01),and the experimental group reached the standard.Conclusions By optimizing the management and quality control system of TCM medical records and the construction of evaluation mechanism,the connotation of medical records and the quality of data on the first page data can be significantly improved,and the rational use of health insurance funds can be promoted.
关键词
中医病案/病案管理/病案质量控制
Key words
TCM medical records/medical record management/medical record quality control
维普
万方数据