Analysis of the Current Status and Influencing Factors of the Quality of the Front Page of Inpatient Medical Records in a Tertiary Hospital in Guangxi
Objectives This study aims to explore the factors that affect the quality of the front page of inpatient medical records and to provide some suggestions for improving the quality of the front page of inpatient medical records.Methods The medical record front page information of a tertiary hospital from January 1,2021 to December 31,2021 was exported from the medical record front page system.The quality scoring was performed with reference to the"Quality Specification for Filling in the Data on the Homepage of Inpatient Cases(Provisional)".Logistic regression was used to analyze the influencing factors of the unqualified quality of filling in the front page of the case.Results A total of 48,162 medical records were extracted,of which 126 were unqualified.The risk of failing acute and critical cases was higher than that of non-acute and critical cases(OR=7.694,95％CI=5.407-10.949,P＜0.001).The risk of failing cases with resuscitation was higher than that without resuscitation(OR=1.780,95％CI=1.506-2.103,P＜0.001).The risk of failing cases with surgery/operation was higher than that of cases without surgery/operation(OR=1.190,95％CI=1.153-1.228,P=0.006).The risk of case failure in other specialties(OR=2.409,95％CI=1.562-3.716,P＜0.001)was higher than that in internal medicine.For every additional diagnosis,the risk of unqualified quality of the inpatient medical record cover page increased by 1.051 times(95％CI=1.014-1.089,P=O.006),and for every additional surgery,the risk of unqualified quality of the inpatient medical record cover page increased by 1.064 times(95％CI=1.007-1.124,P=0.028).Conclusions The quality of the front page of the case in this hospital needs to be further strengthened.Critical cases,whether or not there was rescue,whether or not there was surgery,the number of diagnoses,the number of surgeries,and the discharge department are factors that affect the quality of filling out the front page of the inpatient medical record.Hospitals should establish a medical record quality management system that involves multi-department collaboration and full staff participation and improve the quality of writing the front page of inpatient medical records through various means.
Medical record front pageQuality controlInfluencing factors
万方数据
维普
