Quality analysis of inpatient medical records front page in a tertiary hospital in guangzhou under the DIP model
10.3969/j.issn.1671-332X.2025.01.012
- VernacularTitle:DIP模式下广州市某三甲医院住院病案首页质量分析
- Author:
Nana TIAN
1
;
Qiong DENG
1
;
Deliang LI
1
;
Weicheng ZHOU
1
;
Mengling LI
1
;
Fangfang LIU
1
;
Yu GAN
1
Author Information
1. 广州医科大学附属第五医院 广东 广州 510700
- Publication Type:Journal Article
- Keywords:
DIP;
Inpatient medical records front page;
Quality management
- From:
Modern Hospital
2025;25(1):41-44,48
- CountryChina
- Language:Chinese
-
Abstract:
Objective The aim of this study is to understand the quality of the medical records front page,analyze the reasons,and propose targeted measures to continuously improve the quality of medical records front page,providing accurate and reliable data assurance for the DIP model.Methods A stratified sampling method was used to select 15 020 discharged medical records from a tertiary hospital in Guangzhou from 2022 to 2023.Senior coders performed quality control on the selected medical records front page using a double-person double-quality control mode.Data collection was conducted using Microsoft Excel 2007,and statistical description was performed using SPSS 26.0.Results The defect rate of the medical records front page in the stud-ied tertiary hospital in Guangzhou was 19.91％.The defect rates for non-surgical departments and surgical departments were 17.26％and 23.40％,respectively.There were 4,121 cases(49.28％)with information system transmission errors.The main defects affecting DIP inclusion in the medical records front page were the primary surgical or operative procedure name(903 ca-ses,10.80％)and the primary diagnosis(828 cases,9.90％).Conclusion The defect rate of the medical records front page in the studied tertiary hospital in Guangzhou is at a medium-to-high level,with prominent issues of information system transmis-sion errors and defects affecting DIP inclusion.Measures such as strengthening information construction,enhancing training and communication,and organizing medical records front page knowledge competitions should be implemented to improve the quality of medical records front page.
