Analysis on the Application Value of Special Quality Control on the First Page of Inpatient Medical Records
Objective To explore the application value of special quality control on the first page of inpatient medical records.Methods A total of 2,000 complete medical records of patients hospitalized in Zibo Maternal and Child Health Hospital from May 2022 to May 2023 and 20 staff of the medical record room during the same period were se-lected as the research and analysis objects.They were divided according to the quality control method of the first page of inpatient medical records.The observation group implemented special quality control management of the basic in-formation on the first page of the inpatient medical records in this study,while the control group implemented rou-tine management of the basic information on the first page of the medical records.Compare the quality control scores of the first pages of the two groups of medical records,the common sources of errors on the first pages of medical records,and the time taken to fill in the first pages of medical records and the completion rate of filling in the first pages when archiving the medical records.And compare the overall work efficiency evaluation scores of the two groups of staff.Results The quality control scores of the medical record home page of the internal medicine sys-tem,surgical system,obstetrics and gynecology system and pediatric system in the observation group were all higher than those in the control group,and the difference was statistically significant(P<0.05).Among the common errors on the first page of the medical records in the observation group,the error rate of missing rescue information,missing ad-dress and postal code,missing surgery and operations,and incorrect filling in the method of discharge from the hospi-tal were all lower than those in the control group,and the observation group took less time to fill in the first page of the medical records than the control group,and the completion rate of filling in the first page of the medical records when filing was higher than the control group,the differences were statistically significant(all P<0.05).And the overall work efficiency evaluation score of the staff in the observation group was higher than that in the control group,and the dif-ference was statistically significant(P<0.05).Conclusion Conducting special quality control on the basic information on the home page of inpatient medical records can significantly improve the quality control score of the home page of medical records,reduce the proportion of missed and incorrect entries,improve the filling efficiency,ensure the com-pleteness of the home page,and improve the work efficiency of medical record managers.
Inpatient medical recordsMedical record home pageBasic informationSpecial quality control
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