Analysis of Medical Record Writing and Management Status of Internet Hospitals in Chongqing
- VernacularTitle:重庆市互联网医院病历书写及管理现状分析
- Author:
Fenghai LIU
1
;
Ling XU
1
;
Yonghong HE
1
;
Qiao YANG
1
;
Juan WANG
1
;
Diansa GAO
1
Author Information
1. 重庆医科大学附属第一医院 重庆 400016
- Publication Type:Journal Article
- Keywords:
internet hospitals;
medical record writing;
medical record management
- From:
Chinese Hospital Management
2025;45(12):63-65
- CountryChina
- Language:Chinese
-
Abstract:
Objective To investigate the current situation of medical record writing and management in lnternet hospitals in Chongqing.Methods The medical record writing,medical record management and medical record risk of 45 lnternet hospitals in Chongqing were investigated by questionnaire and expert consultation.Results ln terms of lnternet medical record management,80.95%of them are structured medical records.61.90%had the quality control standard for medical records of lnternet hospitals.76.19%took the current quality control standard of medical records of general outpatient service as the quality control standard of medical records of lnternet hospitals.59.52%of them had a special person responsible for the quality control of medical records on the lnternet.ln terms of lnternet writing,47.62%of the current lnternet electronic medical records are simpler in format and content than the outpatient medical records of physical medical institutions,and 45.24%are consistent.Only 28.57%of people believe that the identity information of guardians of young children or patients with mental disorders needs to be recorded in medical records.ln terms of the risks of lnternet medical records,78.57%believed that there were risks in the management and writing of lnternet medical records.After medical disputes occurred,85.72%of the lnternet medical records as a legal support were at risk,of which 33.33%thought the risk was high,and 7.14%thought the risk was particularly high.Conclusion Chongqing's lnternet medical record writing and management ability needs to be further improved.lt is of practical significance to establish national or local or online medical record writing and management standards.
