The Effectiveness of Supervision on the Front Page of Inpatient Medical Records in the Context of Performance Appraisal in Tertiary Public Hospitals
Objectives This study aims to further investigate the performance appraisal indicators and connotations of tertiary public hospitals to improve the quality of filling in the front page of inpatient medical records and promote refined hospital management.Methods At the end of 2019,a hospital conducted inpatient medical record front page training for all staff based on the performance appraisal indicator system of tertiary public hospitals to optimize each link and began to implement new medical record homepage quality control and assessment standards on January 1,2020.5,000 front pages of inpatient medical records from January 1,2019 to December 31,2019(before training)and from January 1,2020 to December 31,2020(after training)were randomly selected for quality inspection.SPSS26.0 was used for statistical analysis.Results The defects of the front page of hospitalization records were reflected in the vacancy of information filling and non-standard writing.Compared with the quality before the training in 2019,the overall quality of the front page of inpatient medical records in 2020 after the training was significantly better.Errors in the four categories of projects A,B,C,and D had reduced dramatically.Not only did the overall excellent rate increase by 25.44％,but the defective rate of basic information and diagnosis and treatment information dropped from 54.54％and 36.35％to 49.55％and 30.82％respectively.In addition,the defect rates of disease diagnosis and surgical operation in category D items in basic information and category A items in diagnosis and treatment information also dropped from 59.26％and 36.35％to 58.91％and 30.82％respectively.Conclusions The establishment of an inpatient medical record front page quality monitoring system guided by the inpatient medical record front page indicators for performance assessment of tertiary public hospitals,the training of medical staff in the hospital,the optimization of information systems,the establishment of punishment and reward mechanisms,and the supervision and management of medical records will help continuously improve the quality of inpatient medical records,so as to lay a solid foundation for the performance evaluation of tertiary public hospitals.
Front page of inpatient medical recordsQuality controlContinuous improvement
NETL
NSTL
万方数据
