Quality Evaluation of Inpatient Medical Record Front Page Based on Information Technology
Objectives This study aims to use information technology to evaluate the data on the front page of inpatient medical records to provide a reference for improving the quality of data on the front page of inpatient medical records.Methods According to the basic rules for disease and surgical coding,the principles for selecting major diagnoses,and the standards for reporting performance evaluation data in public hospitals,validation rules were set up to automatically generate non-standard medical record front page information and prompt detailed errors,which were checked and made corrections one by one by the quality control physicians,from January 1,2023 to Jane 31,2023.Results Among 51,185 medical records,15,369 medical records had defects,of which the internal medicine defect rate was 28.46％and the surgical defect rate was 31.30％.The difference was statistically significant(x2=48.36,P＜0.05).8696 medical records had 1 defect,5963 medical records had 2 defects,632 medical records had 3 defects,69 medical records had 4 defects,7 medical records had 5 defects,and 2 medical records had 6 defects,accounting for 56.58％,38.80％,4.11％,0.45％,0.05％,and 0.01％,respectively.Conclusions Based on information technology,it is possible to evaluate the quality of the home page of inpatient medical records quickly and efficiently.The defects on the front page of hospitalization medical records mainly involve two parts:basic information and diagnosis and treatment information.However,the rules for assessing the connotation and quality of diagnosis and treatment information need to be further explored.
Front page of inpatient medical recordsQualityInformation technology
NETL
NSTL
万方数据
