Quality Analysis and Countermeasures of Filling out the Front Page of Inpatient Medical Records in a Hospital in Guangdong Province from 2020 to 2022
Objectives By analyzing the data reported on the front page of inpatient medical records in a hospital in Guangdong Province in the past three years,this study aims to identify the causes of defects in front page diagnosis and surgical procedures and propose continuous improvement measures,so as to improve the accuracy of filling out the front page of the inpatient medical record.Methods According to the Quality Specification for Filling in Data on the Front Page of Inpatient Medical Records(Provisional)and Quality Scoring Standard for Data on the Front Page of Inpatient Medical Records(2016 Edition),the quality of 55 705 inpatient medical records from a hospital in Guangdong Province between January 1,2020 and December 31,2022 was monitored and the problems in filling out the front page of inpatient medical records were analyzed.Results Total of 2492 inpatient medical records were filled with defects on the front page,with an overall defect rate of 4.47％.There were 2626 filling defects classified into 26 items according to different types,all of which were related to defects in patient basic information,hospitalization process information,and diagnosis and treatment information.The top four types of problems with a high proportion were defects in main diagnostic information(40.63％),defects in main surgical or operational information(17.44％),defects in other surgical or operational information(14.28％),and defects in other diagnostic information(14.17％).Conclusions The main problems on the front page of the inpatient medical record are the inaccurate selection of main diagnosis on the front page of inpatient medical records,omission of other diagnoses,and omission of surgical or operational information.It is recommended to strengthen training on ICD coding and front-page filling rules for clinicians and coders,promote information construction at hospital level,make full use of continuous improvement measures such as the intelligent review system on the front page and so on,and improve the accuracy of filling in the front page of medical records.The above methods can effectively improve the accuracy of filling in the front page of medical records.
Hospital medical recordsDiagnosis and surgical or operation fillingICD codeQuality control
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NSTL
万方数据
