The role of the key items list in the quality control of running medical records of a children's hospital
10.3969/j.issn.1671-332X.2024.03.012
- VernacularTitle:重点项目清单在儿童医院运行病历质量管理中的作用
- Author:
Xiao CHENG
1
;
Chen JI
;
Minpeng ZHAO
;
Zhencai DONG
;
Lijing LI
Author Information
1. 天津市儿童医院//天津大学儿童医院 天津 300134
- Keywords:
Running medical records;
Quality control;
Goal-setting theory;
Improvement effect
- From:
Modern Hospital
2024;24(3):371-373
- CountryChina
- Language:Chinese
-
Abstract:
Objective To analyze the role of the key items list in the quality control of running medical records by com-paring the improvements of the quality of medical records,and to explore more effective ways of quality management of medical records.Methods Based on the goal setting theory and influencing factors of goal incentive utility,a list of key items for medi-cal record quality management was formulated,which was implemented in a children's hospital in Tianjin since April 2023.A to-tal of 4 823 operating medical records were collected from June 2022 to September 2023,and the defect rates of quality control items were compared by using statistical methods.Results After the implementation of the key items list,the average score of operating medical records was improved,and the defect rate decreased from 13.63％to 7.94％.Moreover,the defect rates of admission records,first-trip records,senior physician rounds records,consultation records,and surgical records decreased from 4.25％,3.07％,8.26％,and 10.56％to 1.61％,1.56％,4.41％,and 5.06％.Conclusion The implementation of key i-tems list management can effectively improve the quality of running medical records,reduce the defects of medical records,and improve the effects of medical record management.
