Quality Analysis of Defective Medical Records in 1803 Proposed Diagnostic Discussions
Objectives This study aims to analyze the defects of the first medical record and discussion of the proposed diagnosis in the final medical record writing,and seek improvement measures,so as to strengthen the quality management of medical records and improve the connotation quality of medical records.Methods 58,552 terminal medical records were retrieved from a comprehensive tertiary hospital from January 1,2021 to December 31,2022.The defective diagnosis discussions were classified by quality defects and statistical analysis was performed on the data.Results In the 1803 records,the most common writing defect in the proposed diagnosis discussion was that different diagnosis did not propose differential points/expansion based on the condition,accounting for 37.7％.In addition,there were 469 defective diagnostic bases,accounting for 26.01％of the total.341 reports with a clear diagnosis but no discussion of treatment and prognosis,accounting for 18.91％of the total.303 reports failed to propose the best treatment plan based on the patient's condition,accounting for 16.81％of the total.Among the medical and surgical records,surgical defects accounted for 38.99％and internal medicine defects accounted for 35.66％.Conclusions In the quality control of medical records,it was found that there were serious deficiencies in the first medical course record,proposed diagnosis and discussion.It is necessary to strengthen its standardized writing,enhance the ability of physicians to analyze and diagnose diseases,deepen their understanding of disease treatment prognosis,and promote the joint improvement of the connotation and quality of medical records and medical care.
万方数据
维普
