1.Quality of inpatient medical records based on quality control indicators for medical record manage-ment
Baojuan LIN ; Zhu WEI ; Yican CHEN ; Lirong CHEN ; Wenqing QUE ; Yu LIU ; Fudi SU
Modern Hospital 2025;25(5):726-728,733
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.
2.Quality of inpatient medical records based on quality control indicators for medical record manage-ment
Baojuan LIN ; Zhu WEI ; Yican CHEN ; Lirong CHEN ; Wenqing QUE ; Yu LIU ; Fudi SU
Modern Hospital 2025;25(5):726-728,733
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.
3.Influence of psychological intervention on physical and psychomotor development of children born of assisted reproductive technology
Xianghong CHEN ; Shunhao MENG ; Qiyun LUO ; Yuzhen CHEN ; Wenchang YU ; Wenqing QUE
Chinese Journal of Practical Nursing 2012;28(4):14-16
Objective To investigate the influence of psychological intervention on the physical and psychomotor development of children born of assisted reproductive technology. Methods 329 cases of ART born children in our hospital were set as the experimental group,the parturients were given pertinent psychological intervention.254 cases of children of spontaneous pregnancy were selected as the control group.The two groups were given follow-up for 24 months.Their physical condition at birth and psychomotor development during follow - up period were compared. Results Compared with the control group,length of infants at birth,body mass of the experimental group were significantly lower,and the incidence rate of premature birth,low birth weight,NICU stay during neonatal stage were higher.But there were no differences in psychomotor development between two groups. Conclusions ART born children of 24-month old show normal psychomotor development,but there are still more unfavorable physical factors,therefore,pertinent nursing intervention should be given based upon psychological intervention in clinic.

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