Quality Analysis of Medical Record Writing in Human Assisted Reproductive Technology
Objectives To analyze the current situation of medical record writing of human assisted reproduction technology in a hospital in Guangxi Zhuang Autonomous Region,find out the existing problems of medical record writing,and explore the countermeasures and methods to improve the quality of medical record writing.Methods A total of 5370 medical records of human assisted reproductive technology were selected from the medical records information system of a reproductive center of a hospital from January 1st,2022 to December 31st,2022 by cluster sampling method.The quality control team of the department conducted quality inspection according to the requirements of medical records quality control,and carried out statistical analysis on the classification of defects and the number of defects.Results There were 1236 defect records in 5370 medical records,with a total defect rate of 23.02%and 1835 defects.The defects were divided into nine categories according to the items,and the defect rate was the medical history(48.34%),informed consent(15.37%),controlled super-ovulation monitoring table(10.30%),egg operation records(10.19%),front page of ART outpatient medical record(7.14%),other items(4.96%),embryo laboratory records(1.74%),transplant records(1.36%),and course record/case discussion(0.60%).Conclusions The highest defect rate was the lack of medical history records of the couple,followed by the incomplete filling of the informed consent form,the omission of the controlled super-ovulation monitoring form and the incomplete records of spawning surgery.The hospital needed to strengthen the study of the diagnosis and treatment norms of human assisted reproductive technology,improve the quality control and management system of medical records,promote the quality of medical records writing,and then improve the medical quality and medical service level of the hospital.
Medical record writingHuman assisted reproductive technologyDefectsQualityCountermeasures