Effect Evaluation of Automatic Medical Record Quality Control System
Objective To establish and optimize the automatic quality control system of hospital medical records on the basis of information construction,and to monitor the running medical records continuously,dynamically and effectively,so as to improve the quality of medical records.Methods Our study was carried out in one of the Grade-A Tertiary Hospitals in Beijing.A quality control and management scheme of running medical records was established on the basis of electronic medical record system.The quality control system automatically detected,analyzed and evaluated the running medical records,and fed the results back to the hospital leaders and department directors through a variety of channels,so that they could grasp the quality of running medical records and respond in time.Results There was no significant difference in the score of manual sampling medical record quality control and running medical record automatic quality control.The Monthly qualified rate of running medical records in September 2022 was 33.81%higher than that of 2021 in the same period.During the study period,the quarter-on-quarter growth rate of the qualified rate of running medical records was 0.15%-18.12%.Conclusion The running medical records quality control system can effectively improve the coverage and timeliness of medical records quality control.It is helpful to standardize the writing of medical records,strengthen medical quality,improve medical services and ensure medical safety.
automationmedical record quality control systemrunning medical record
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