The Current Situation and Research Progress in Filling Out the Front Page of Inpatient Medical Records
Objectives This study aims to retrieve relevant literature on the front page of inpatient medical records from 2018 to 2022,summarize the problems in filling out the front page of inpatient medical records in Chinese hospitals at present,analyze the reasons for filling out defects,summarize quality control methods,and propose management strategies,so as to provide a reference for improving the quality of filling out the front page of medical records.Methods Based on the China National Knowledge Infrastructure(CNKI),relevant literature from 2018 to 2022 was searched using the search terms"front page of hospitalization medical records"or"defects".Representative literatures were analyzed and summarized.Results Through literature review and summary,140 relevant literatures were included,with the highest number of publications in 2022,mainly concentrated in the Chinese Medical Records.The retrieved literature involved a total of 130,496 medical records,and 20,322 medical records(15.57％)had defects.Among them,40.28％were not filled in the work unit,address,phone number,and zip code,and 28.83％were incorrectly filled in the main diagnosis.Conclusions The main reasons for errors in filling out the first page of inpatient medical records are low emphasis on quality,incomplete division of departmental powers and information systems,and lack of formal training.Proposing targeted measures for the problems that arise can effectively improve the quality of the medical record front page.
Front pages of inpatient medical recordsReason analysisQuality controlManagement strategy
万方数据
维普
