Factors Influencing the Quality of In-Patient Medical Records Filling in the First Page of Grade A Tertiary Hospital in a Province and Countermeasures
Objective To study the influencing factors and countermeasures of the quality of in-patient medical records filling on the first page of grade A tertiary hospital.Methods A total of 3 976 inpatient medical records from February 2022 to October 2023 in a provincial grade A tertiary hospital were selected as the object of this study,and at the same time,according to 3 976 inpatient medical records,the specific personal information of 249 resident doctors was investigated,and the influencing factors were analyzed.Results In this study,male resident doctor accounted for a relatively high proportion of 61.85%.Doctors mainly came from clinical staff,accounting for 54.62%.The master's degree accounted for 53.41%of doctors'education.Most of the working time is more than 1 year.In the training of residents in filling out the first page of medical records,there was still a lot of room for improvement as a whole,and residents'autonomous learning initiative also needs to be improved.The overall cognition level of residents on the quality of information filling in the first page of medical records was low,which needs to be improved.The results of multivariate logistic regression analysis showed that the working hours of residents,the standardized operation training of residents,the training of information filling on the front page of medical records,and the quality control of random check on the front page of medical records were the main factors affecting the quality of information filling on the front page of medical records(P<0.05).Conclusion Working hours of residents,standardized operation training of residents,information filling training on the front page of medical records,and random check quality control on the front page of medical records are the main factors affecting the quality of information filling on the front page of medical records.By taking corresponding improvement measures according to the influencing factors in time,the quality of information filling on the front page of medical records can be effectively improved significantly.Promote the continuous improvement of the quality of follow-up medical record information management.
inpatient medical recordsfill in the quality on the first pageinfluencing factorscountermeasureshome page spot check quality controlworking hours
万方数据
维普
