Problems and Countermeasures of Quality Management of the Front Page of Inpatient Medical Records
Objective To analyze the current situation of quality management of the front page of inpatient medical records,identify the problems and propose targeted solutions,so as to provide reference and basis for improving quality management of the front page of inpatient medical records.Methods A total of 10,524 medical records were selected from different clinical departments in the hospital from January 1st,2021 to December 31st,2022,including 4,923 records in 2021 and 5,601 records in 2022.The defects(missed filling and wrong filling)on the front page of inpatient medical records and the types of defects(patient basic information,information during hospitalization and information about diagnosis and treatment)in 2021 and 2022 were compared.The composition ratios of defect categories on the front page of inpatient medical records were analyzed.Results The rates of missed filling and wrong filling,and the total incidence of defects on the front page of inpatient medical records in 2022 were lower than those in 2021(P＜0.05).There were 2,181 medical records with defects on the front page,and there were 2,882 defective items.Among them,the proportion of defects in diagnosis and treatment information was the highest(74.05％),followed by defects in information during hospitalization(13.08％)and defects in patient basic information(12.87％).The missed filling rate of comatose time in craniocerebral injury was the highest(55.56％),followed by neonatal birth weight(2.14％).The wrong filling rate of operation and procedures was the highest(7.52％),followed by primary diagnosis(5.25％).The defect rate of comatose time in craniocerebral injury was the highest(55.56％),followed by operation and procedures(9.06％).The incidence rates of defects in patient basic information,information during hospitalization and information about diagnosis and treatment on the front page of inpatient medical records in 2022 were lower than those in 2021(P＜0.05).Conclusions The quality management of the front page of inpatient medical records was not ideal.Measures such as strengthening training,improving relevant management systems,establishing a quality control network for the front page of inpatient medical records,improving management methods,building a diagnosis and treatment information database,and increasing communication channels between medical records and clinical practice could be taken to reduce defects in the front page of inpatient medical records and improve the front page quality of inpatient medical records.
Front page of inpatient medical recordManagementProblemCountermeasure
NETL
NSTL
万方数据
