Analysis on the Writing Quality of the First Medical Record in a Certain Hospital
Objectives By analyzing the defects in the first medical record of a certain hospital,this study aims to explore the rectification path and effectively improve the connotation and quality of medical records.Methods According to the requirements of the"Basic Norms for Medical Record Writing"issued by the former Ministry of Health,a total of 2,524 discharged medical records from a certain hospital or surgery from October 1 to November 30,2023 were investigated.Descriptive statistical analysis was conducted on the defective initial records.Results The total average score of the first medical record of the inpatient medical record was(87.35±2.63 points);the average score of the first medical record of the surgical department was(82.54±2.14 points),and the average score of the first medical record of the internal medicine department was(91.81±2.76 points).683 medical records had defects in the first course of illness,accounting for 27.06％of all medical records.The first course defects were divided into 9 categories,with a total of 733 cases of defects in each category.Among them,18.83％of the cases had insufficient diagnostic basis,14.05％of the cases had lack of summary and refinement of case characteristics,and 13.37％of the cases had omissions in the diagnosis and treatment plan.Conclusions There are certain deficiencies in the first stage of medical records.Hospitals should strengthen systematic training on medical record writing,enhance awareness of preventing medical disputes,and innovate medical record quality control models to effectively improve the quality of the first medical record,improve the hospital's medical record management level.
Record of the first course of illnessQuality controlMedical disputesLegal awarenessArtificial intelligence
NETL
NSTL
万方数据
