Quality Analysis of the Front Page of Inpatient Medical Records in a Second Class Public Hospital in Wuhan
Objectives To investigate the quality of the front page of inpatient medical records in a secondary public hospital,analyze the reasons for the problems on the front page of inpatient medical records,and conduct countermeasures research.Methods A special inspection team was established for the front page of inpatient medical records,with coders and end-users as the core.9947 inpatient medical records from a secondary public hospital from January 1st,2022 to December 31st,2022 were examined for basic information,hospitalization process information,diagnostic information,and surgical information,and the defect rate of the front page of inpatient medical records was calculated.Results There were 1267 defective medical records,with a defect rate of 12.74%on the front page of inpatient medical records and 1683 defective items;457 medical records of diagnostic information defects,including 194 other diagnostic defects and 103 main diagnostic defects.The defect items included diagnostic omissions,insufficient diagnostic basis,and diagnostic upgrades;332 medical records with surgical information defects,with core issues focused on missing or invasive procedures,inconsistency between surgery and surgical records on the front page of inpatient medical records,and major surgical errors;There were 478 deficiencies in basic information and hospitalization process information,all of which were integrity and logical issues.Conclusion The hospital should establish a comprehensive three-level quality control system for the front page of inpatient medical records,to achieve a benign closed-loop management process for the front page of inpatient medical records;To improve the ability and awareness of clinical physicians to fill out the front page of inpatient medical records through training;Strengthen hospital information construction and reduce logical and complete defects in the front page of inpatient medical records.
NETL
NSTL
万方数据
