Quality Analysis of the Inpatient Medical Record Front Page of Death Cases in a Tertiary Hospital
Objectives The purpose of this article is to analyze the current situation of filling out the front page of death medical records in a tertiary hospital,explore improvement measures,and thereby improve the accuracy of filling out the front page of death medical records.Methods A total of 267 death medical records from a tertiary hospital from January 1,2022 to December 31,2022 were retrieved from the medical record system.A medical record quality control expert team consisting of three experienced clinical physicians was selected to check the front pages of the inpatient medical records of death cases,and counted and recorded the problems that occurred on the first pages of the inpatient medical records of death cases.Results The number of defective medical records on the front page of 267 death inpatient medical records was 121,accounting for 45.32％.Among them,there were 33 cases of basic information defects in patients,accounting for 27.28％of the defective inpatient medical records;There were 16 cases of information defects in the hospitalization process,accounting for 13.22％of the defective hospitalization medical records;There were 72 cases of information defects in diagnosis and treatment,accounting for 59.50％of the total number of defective inpatient medical records.There were 23 medical records with incorrect selection and coding of the main diagnosis,accounting for 19.01％.The Department of Critical Care Medicine had the highest percentage of errors,accounting for 28.93％,followed by Neurosurgery,accounting for 23.97％.The defects in non-surgical departments were lower than those in surgical departments.Conclusions There are certain defects in the quality of the front page of the inpatient medical record of death cases in a certain hospital.It is necessary to strengthen the training and education of medical personnel,optimize the diagnosis and treatment information recording process,and strengthen quality control and supervision to improve the quality of filling out the front page of inpatient medical records.
Hospitalization medical record front pageDefectsQuality research
万方数据
维普
