Analysis and Continuous Improvement of Defects on the Front Page of 16,231 Inpatient Medical Records
Objectives This study aims to conduct quality control on the front page of inpatient medical records,analyze the causes of defects,provide accurate feedback,and continuously improve the quality of filling out the front page of inpatient medical records.Methods Two full-time coders conducted quality control on the front pages of a hospital's inpatient medical records from January 1,2022 to December 31,2022.Among them,there were 1,496 reports in total during the defective project survey phase from January 1,2022 to January 31,2022,which is the first group;there were 6,786 reports in total during the precise feedback phase from February 1,2022 to June 30,2022,which is the second group;there were 7,949 reports in total during the enhanced assessment phase from July 1,2022 to December 31,2022,which is the third group.Results Among the front pages of 16,231 inpatient medical records,3,439 records had 5,987 defective contents.Among them,defects in diagnosis and treatment information accounted for 61.02％,and 33.59％of surgical operations were missed.There were 2011 cases of surgical operation omissions,of which 19.79％were related to traditional Chinese medicine rehabilitation and 10.45％were related to ventilator use.The defect rates were 30.95％in group 1,25.95％in group 2,and 15.28％in group 3.There were statistically significant differences among the groups(P＜0.01).Conclusions Strengthening the quality control of the first page of inpatient medical records can effectively reduce its defect rate.Hospitals should strengthen information management,establish long-term mechanisms,provide accurate feedback and assessment,strengthen talent training,and continuously improve the quality of the first page of inpatient medical records.
Front page of inpatient medical recordsDefectsQuality managementContinuous improvement
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