Analysis of Problems and Countermeasures on the Front Page of Inpatient Medical Records in a Specialized Hospital in Suzhou
Objectives This study aims to summarize and analyze the quality of the front page of inpatient medical records in the past three years and put forward the countermeasures to improve the quality of inpatient medical record front pages.Methods A total of 2401 medical records were randomly selected according to major and proportion from January 1,2020 to December 31,2022.The method of descriptive analysis was used to sort and classify the quality control status of extracted inpatient medical records.The overall situation,projects,departments,and other elements of defects on the front pages of the 654 inpatient medical records detected were collected and summarized,and the relevant data were statistically analyzed using Excel.Results Defects on the front page of the hospital's inpatient medical records accounted for 27.24％.In the sub-statistics,the ICD coding defect rate ranked first,accounting for 34.09％.In the surgical departments,the Burns and Plastic Surgery Department had the highest defect rate on the front page of inpatient medical records,accounting for 9.93％.Among non-surgical departments,the hematology department had the highest defect rate on the front page of inpatient medical records,accounting for 13.12％.Conclusions The front page of a certain hospital's inpatient medical records has a high defect rate,and the coding defect rate ranks first.The quality of the front page of inpatient medical records in departments with fast bed turnover and many surgeries is not high.Hospitals should improve the quality of the inpatient medical record front page by strengthening training,strengthening error correction throughout the coding chain,improving the assessment mechanism,and improving the level of informatization.
Front page of medical recordProblem analysisCountermeasure research
NETL
NSTL
万方数据
