Quality of inpatient medical records based on quality control indicators for medical record manage-ment
10.3969/j.issn.1671-332X.2025.05.018
- VernacularTitle:基于病案管理质量控制指标的住院病历内涵质量现状分析
- Author:
Baojuan LIN
1
;
Zhu WEI
;
Yican CHEN
;
Lirong CHEN
;
Wenqing QUE
;
Yu LIU
;
Fudi SU
Author Information
1. 中山大学孙逸仙纪念医院 广东 广州 510120
- Publication Type:Journal Article
- Keywords:
Medical record quality control indicators;
Hospice medical records;
Documentation integrity
- From:
Modern Hospital
2025;25(5):726-728,733
- CountryChina
- Language:Chinese
-
Abstract:
Objective Guided by"Medical Record Management Quality Control Indicators(2021 Edition)"(hereafter regarded as Medical Record Quality Indicators),this study aims to evaluate the quality of inpatient hospice medical records at a tertiary hospital in Guangzhou.Methods A total of 1,071 inpatient hospice medical records from the year 2023 in a tertiary gen-eral hospital in Guangzhou were selected for evaluation.The evaluation focused on three aspects:documentation compliance of documentation of critical examinations(including CT/MRI,pathology,and pathogen examinations),the compliance rate of treat-ment behavior records(encompassing antibiotic usage,chemotherapy or radiotherapy or targeted or immunotherapy for malignant tumors,and surgical records),and the incidence of unreasonable duplication within medical record.Results The compliance rate for major examination records ranged from 47.7％to 100.0％,with the lowest compliance rate(47.7％)observed in docu-mentation of pathogen culture analysis.Treatment behavior documentation compliance varied from 49.1％to 100.0％,with the lowest compliance rate of 49.1％observed in the recording of antibiotic usage.Rates of inappropriate duplication ranged from 1.0％to duplication(63.1％),with the highest rate of 63.1％occurring when initial progress notes replicated admission histo-ries without synthesis(63.1％).Conclusion The Medical Record Management Quality Control Indicators serves as an effective tool for evaluating the dimensions of medical record quality and offers a systematic framework for enhancing documentation integri-ty within hospitals.
