Research on Defect Analysis and Improvement Measures of Discharge Di-agnosis Filling in the Front Page of Inpatient Medical Records
Objective To explore the defect analysis and improvement measures of discharge diagnosis filling in the first page of inpatient medical records.Methods From January 2021 to June 2023,the first page information of medi-cal records of inpatients admitted to Liqun Hospital of Putuo District in Shanghai was selected as the research object.From January to December 2021,the first page information of 8 000 patients was managed by routine management mode(control group).From August 2022 to June 2023,the first page information of 8 000 patients was managed by optimized and improved management mode(study group).The medical records of key departments in the hospital were randomly selected.The incidence of discharge diagnosis and filling defects on the first page of medical records and the management quality of the first page of medical records in the two groups were analyzed.Results In the study group,there were 68 cases of missing other diagnosis,non-standard diagnosis and wrong choice of main diagnosis in the discharge diagnosis,accounting for 0.85%,there were 157 cases of the above defects in the control group,account-ing for 1.96%,the study group was lower than the control group,and the difference was statistically significant(χ2=35.707,P<0.05).The accuracy(78.96±2.84)points,standardization(80.22±2.97)points and integrity(80.25±2.33)points of the discharge diagnosis of the medical record management in the study group were higher than those in the control group(62.69±2.45)points,(65.69±2.84)points,(63.96±2.98)points,the difference was statistically significant(t=387.985,316.257,385.174,P<0.05).Conclusion The defects of filling in the first page of hospitalization medical records have been improved after the implementation of improvement measures.In the future medical records manage-ment,it is necessary to strengthen the management research on clinicians,and actively carry out normative training on filling in the first page information of medical records,and take effective management measures to improve the quality of information on the first page of medical records.
Inpatient recordsDischarge diagnosisFill in defectsImprovement measure
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NSTL
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