Analysis of Defects and Countermeasure Research on Front Page of 1200 Medical Records in a Hospital
Objectives By analyzing the quality of the front page of inpatient medical records,summarizing the defects of the front page of inpatient medical records,analyzing the causes of the defects,and conducting countermeasures for the exposed problems,in order to better improve the filling quality of the front page of inpatient medical records.Methods According to the requirements of the 2016 edition of the"Quality Specification for Data Filling in the Front page of Inpatient Medical Records(Interim)"and the 2010 edition of the"Basic Specification for Writing Medical Records",five experienced clinicians were selected by the medical records Management Committee to set up an expert quality control group.1200 inpatient medical records from January 1st,2023 to June 30th,2023 were randomly selected to analyze the defects of the inpatient medical records.Result Among 1200 inpatient medical records,477 were defective,with a defect rate of 39.75%.Among them,the main diagnosis defect rate was the highest 8.50%,followed by the main surgery defect rate of 8.00%.According to the statistics of the departments,the defect rate of the department of intensive care medicine was the highest 51.67%,and the defect rate of the department of neurology was the lowest 24.73%.Conclusions The quality problems of diagnosis and treatment filling in the front page of inpatient medical records were still prominent,in which the main diagnostic selection errors and nominally irregular defect rates were the highest,and the defect rate of critical care medicine was the highest according to the statistics of the department.We should strengthen the training of medical records writing and the quality control of links,establish an effective management mechanism,and further improve the quality of the front page of inpatient medical records.
Front page of medical recordsDefectCountermeasures
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