Analysis of the Connotation Defects of Medical Records in Cancer Hospi-tals and Countermeasures
Objective To understand the existing problems in the quality of medical records in oncology specialty through end-stage quality control,provide feedback to clinical practice,and guide improvement to enhance the qual-ity of medical records.Methods A total of 29 820 medical records of patients discharged from Tianjin Medical Univer-sity Cancer Hospital from January to December 2023 were selected as the research objects.Experts and quality in-spectors were organized to analyze and evaluate the content of medical records based on the examination standards.Excel 2003 table was used to summarize and sort out the data,and descriptive statistical analysis was carried out on the distribution of quality defects in medical records.Results A total of 29 820 medical records were randomly se-lected for examination,with a total of 58 749 defective items.The top five defective items were:copying the first medi-cal course record without induction and extraction,defects in preoperative discussion records,missing or non-standard surgical records,missing or non-standard informed consent forms,and non-standard or overly simple diagno-sis and treatment process records in discharge records,accounting for 13.16%,7.34%,5.53%,5.17%,and 4.90%,re-spectively.Conclusion There are still many deficiencies in the writing of medical records in this hospital,mainly con-centrated in the first course of illness records,perioperative records,informed consent forms,discharge records,etc.Corresponding measures need to be taken to continuously improve the quality of medical records and reduce the de-fect rate of medical records.
万方数据
维普
