Analysis of Factors Affecting The Accuracy of Main Diagnoses on The Front Page of Inpatient Medical Records in a Large Tertiary Hospital
Objectives This study aims to explore the factors that affect the accuracy of the main diagnosis on the front page of clinical doctors'medical records.Methods Data from the front page of inpatient medical records of a large tertiary public hospital in Sichuan Province from June 1,2021 to December 31,2022 were collected.A three-level logistic regression model was used to analyze the influencing factors on the accuracy of clinical doctors'main diagnoses.Results This study included a total of 376,517 discharged medical records,with a primary diagnostic accuracy rate of 82.29％.The results of the regression model showed that training(OR=1.140 for the first training and OR=2.375 for the second training),whether the patient was transferred to another department(OR=0.685),whether the patient was hospitalized repeatedly in the same department(OR=1.416),whether the patient's condition was clear upon admission(OR=1.326),and whether the patient was hospitalized for an extended period of time(OR=0.910)were the main factors affecting the accuracy of the diagnosis.However,there was no statistically significant difference in the impact of department type,number of physicians,average discharge burden per physician,and physician's in-hospital practice time on the correct rate of primary diagnosis.Conclusions Paying attention to the correct selection of main diagnoses in complex medical records,strengthening training on filling out main diagnoses in departments,and developing a quality assessment system for filling out main diagnoses are effective ways to improve the accuracy of main diagnoses by clinical doctors.
Main diagnostic accuracyThree level logistic regression modelPublic hospital
NETL
NSTL
万方数据
