The Effect of Logical Verification Rule on the Data Quality of Inpatient Medical Records Front Page in a Tertiary TCM Hospital
Objectives This study aims to discuss the role of logical verification rules on the front page of medical records in improving the quality of the front page of traditional Chinese medicine inpatient medical records,so as to provide a decision-making basis for medical insurance payment,performance evaluation and medical quality safety.Methods 16,399 inpatient medical record front pages from January 1 to June 30,2022 before verification were extracted and used as a control group.The front pages of 18,237 inpatient medical records from July 1,2022 to December 31,2022 were used as the experimental group.Chi-square test was used to analyze the accuracy of filling in the first page of the inpatient medical records of the two groups.Results 305 logical verification rules were formulated based on the standard requirements for filling in the front page of hospitalization medical records.After implementing the logic verification rules,the number of defects dropped from 1970 to 1105,and the accuracy increased from 87.99％to 93.94％.After the chi-square test,x2=377.88,with a significance level of P＜0.05,indicating that most of the differences were statistically significant.Conclusions The implementation of logical verification rules for the front page of all Chinese medicine inpatient medical records,along with corresponding training,has significantly reduced instances of manual omissions and incorrect entries.This has ensured the completeness,accuracy,and rationality of diagnosis and treatment information on these records,ultimately enhancing their quality.
Traditional Chinese MedicineFront page of inpatient medical recordsLogic checkQuality control
万方数据
维普
