Quality Analysis of the Front Page of Key Inpatient Medical Records in a Grade A Tertiary Hospital in NanJing
Objectives This study aims to conduct random inspections on the filling in the front page of the inpatient medical records of key cases in a hospital,make statistical summaries of the results,and propose targeted improvement measures to improve the quality of reporting.Methods 3250 key cases discharged from a certain hospital from July 1,2021 to February 28,2022 were extracted.In accordance with the relevant regulations and requirements of Medical Record Writing Standard(2010)published by the Ministry of Health and the Quality Specification for Filling in Front Page Data(Temporary)published by the National Health and Family Planning Commission,special quality control was carried out on the key items filled in on the front page of the inpatient medical records based on the actual situation of the hospital.Results Statistical analysis of the front page of medical records showed that 1094 medical records were defective,with a cumulative defect rate of 33.66％.The defect rate of the first page of key medical records in non-surgical departments was higher than that in surgical departments,with a statistically significant difference(x2=11.800,P=0.001).The defect rate was highest in the Department of Critical Care Medicine and the lowest in the Department of Obstetrics.The defect content was mostly due to the omission of other diagnoses or inaccurate diagnosis names and the wrong selection of admission conditions,accounting for 63.2％.Other prominent flaws included missed filling surgeries and operations,errors in the selection of major diagnoses,errors in the selection of difficult cases,and errors in the selection of critical cases.Conclusions The quality of writing on the front page of inpatient medical records for key cases in non-surgical departments was worse than that in surgical departments,and the quality of the front pages of inpatient medical records differs significantly between departments.The deficiencies were concentrated in errors and omissions in diagnosis,admission conditions,surgeries and operations,difficult cases,and critical cases.It is recommended to improve the data quality of medical record front pages by strengthening training,improving informatization construction,and establishing a complete medical record homepage quality control system.
Front page of the medical recordsQuality controlDefect analysis
NETL
NSTL
万方数据
维普
