Investigation and Analysis of the Current Status of Medical Record Management in 116 Medical Institutions in a City
Objectives This study aims to understand the construction status of medical record management in 116 medical institutions in a city,analyze the new situation of current medical record management,standardize medical record management,and improve the professional level of medical record staff.Methods On November 30,2022,the Medical Records Management Quality Control Center of a certain city issued a questionnaire to 116 medical institutions within its jurisdiction.Epidata3.02 software was used for data entry,and Microsoft Office Excel 2019 and SPSS23.0 were used for data analysis.Results 53 medical institutions set up independent medical record management departments,accounting for 45.69％.There were differences in age,educational background,professional title and profession in different categories of medical institutions(P＜0.05)and differences in age,gender,educational background,professional title and profession in medical institutions of different nature(P＜0.05).There was a shortage of medical record management personnel and insufficient staffing in public hospitals,especially in tertiary medical institutions.The storage and review methods of medical records in various types of medical institutions at all levels were mainly paper and electronic medical records.The scope of quality control was mainly the quality control of the front page of inpatient medical records,accounting for 78.26％.The main method of medical record quality control was manual quality control,accounting for 58.62％.Conclusions The affiliation of medical record departments in medical institutions in a city is complex,the professional structure of medical record personnel is unreasonable,the professional title level of medical record management personnel is not high,and the quality control methods of medical records are outdated.The next step is to continuously establish and improve the management system of the Medical Record Management Quality Control Center,so as to continuously improve the level of medical record management.
Medical record managementMedical record quality controlMedical institutionsSurvey
NETL
NSTL
万方数据
维普
