Construction and application of a full process quality control system for first pages of medical records
10.3969/j.issn.1671-332X.2024.11.025
- VernacularTitle:病案首页全流程质控体系构建及应用
- Author:
Luming LIU
1
;
Ying LI
;
Wen JIN
;
Xi YIN
Author Information
1. 浙江大学医学院附属第一医院 浙江 杭州 310003
- Keywords:
first pages of inpatient medical records;
Connotative quality;
Quality indicators of medical records;
Full process quality control system
- From:
Modern Hospital
2024;24(11):1722-1725
- CountryChina
- Language:Chinese
-
Abstract:
Objective To construct a full process quality control system for first pages of medical records based on process management and assess the assess the effectiveness.Methods A tertiary hospital has been conducting quality improve-ment actions on the quality control of first pages of the medical records since 2020.To assess the effectiveness,the first pages of the medical records were randomly selected regularly,and the quality of first page writing was examined based on the"Specifica-tion for Filling in the Face Sheet of the Inpatient Medical Record Data(2016 edition)".Subsequently,data processing software was used to monitor the changes in the quality control indicators and the categories of error types.Results Following the imple-mentation of the quality control,the quality of data in the first pages met the standards proposed by the hospital.There was a sig-nificant,year-over-year improvement in quality control indicators and a favorable trend in the composition of error types,with sta-tistically significant differences.Conclusion The full process quality control system for first pages of medical records established by the hospital can effectively enhance the connotative quality of the first pages of medical records.
