Analysis of the Quality of the Front page of Inpatient Medical Records Based on Supervisory Inspection Results at a Selected Hospital
Objectives This study aims to analyze the feedback from the quality supervision inspection on the front page of the inpatient medical records of a certain hospital,so as to improve the quality of data filling on the front page of hospital inpatient medical records.Methods The Beijing Municipal Health and Big Data Policy Research Center organized clinical and coding experts to randomly check 200 inpatient medical records in a certain hospital from January 1,2020 to December 31,2021,using a precise positioning method for suspect problem sampling.The feedback results of the supervision inspection were checked item by item by quality control physicians and coders,and Excel 2013 was used for statistical analysis.Results Among the 200 cases inspected by supervision,there were 145 defective cases,accounting for 72.5％,of which 50 cases had main diagnosis and coding errors,accounting for 25％.The number of cases with incorrect filling and coding of major surgical operations was 20,accounting for 10％.In terms of physicians,there were 45 cases of errors in filling in main diagnoses,10 cases of errors in filling in major surgeries,57 cases of errors in filling in other diagnoses,and 38 cases of errors in filling in other surgeries and operations.In terms of coding,there were 5 major diagnosis coding errors,10 major surgical errors,17 other diagnostic coding errors,and 3 other surgical errors.Conclusions The quality of initial inpatient medical record data reporting at the selected hospital is concerning,primarily due to physicians'inaccurate documentation of diagnoses and surgical procedures.Hospitals should regularly train clinical physicians in standardized documentation of inpatient medical records and enhance the comprehensive clinical thinking of coders to improve the quality of initial inpatient medical records.This is crucial for providing reliable data for DRG and performance assessment in tertiary public hospitals.
Front page of inpatient medical recordsCodingDiagnosisSurgeryOperation
NETL
NSTL
万方数据
