Quality Control Analysis of the Front Page of Inpatient Medical Records Based on the Performance Appraisal of Public Hospitals
Objectives Through analyzing and improving the quality control data of the first page of inpatient medical records,the quality of the front page of inpatient medical records was improved and the statistical accuracy of the front page of inpatient medical records was guaranteed.Methods Retrospective quality control was performed on the front page of 12,971 medical records discharged from January 1st,2022 to March 31st,2022.After PDCA quality control cycle management,12,971 medical records from January 1st,2023 to March 31st,2023 were conducted to track the quality control effect.The collected data of the two groups were processed and analyzed with SPSS statistical analysis software,and the defect rates of the two groups were compared with x2 test analysis,and P＜0.05 was used to indicate statistically significant differences.Results Through quality control and improvement measures,the overall defect rate of the front page of inpatient medical records decreased from 24.45％to 10.51％,P＜0.001.The patient information decreased from 10.43％to 4.53％,the address unknown decreased from 3.95％to 2.08％,the occupation inconsistency decreased from 3.56％to 1.72％,the birthplace and native place error decreased from 3.36％to 1.10％.The content related to diagnosis decreased from 5.48％to 3.20％,the defect rate of major diagnosis selection error decreased from 2.51％to 1.72％,pathological information omission decreased from 0.86％to 0.31％,and discharge outcome error decreased from 0.73％to 0.22％.The content related to surgical procedures decreased from 3.25％to 0.93％,among which surgical grade errors decreased from 1.26％to 0.44％,major surgical procedure errors decreased from 1.06％to 0.28％,surgical sequence errors decreased from 0.97％to 0.22％,and other surgical procedure errors decreased from 0.48％to 0.20％.Other related content decreased from 5.72％to 2.76％,among which incomplete signature decreased from 4.42％to 2.69％,single disease management defect rate decreased from 1.60％to 0.44％,clinical path management error decreased from 0.60％to 0.22％.Conclusions After the improvement of the quality control system,the quality of the front page of hospital medical records was improved,but it was still necessary to improve the quality control measures,especially to establish the cooperation between the staff of various departments.
Public hospital performance appraisalThe front page of inpatient medical recordsQuality control
NETL
NSTL
万方数据
