Quality analysis of medical records of critical patients in a tertiary hospital
10.3969/j.issn.1671-332X.2024.09.019
- VernacularTitle:某三级医院危重患者住院病历质量分析
- Author:
Yanyan ZHU
1
;
Xiaojing HE
;
Yuying LU
;
Qinghai LIU
Author Information
1. 南京医科大学附属逸夫医院 江苏南京 211100
- Keywords:
Critically ill patients;
The quality of medical record;
Defect analysis
- From:
Modern Hospital
2024;24(9):1381-1383,1387
- CountryChina
- Language:Chinese
-
Abstract:
Objective According to a random check of the hospital's critical medical records,classify and summarize the results,analyze the existing problems and their causes,seek to improve the quality of medical record writing measures.Methods 330 out of 1 117 critically medical records discharged from December 1,2022 to November 30,2023 were extracted.According to the related regulations and requirements of Medical Record Writing Standard(2010),Key Points of Medical Quality and Safety Core System,the Quality Specification for Filling in Front Page Data(Temporary)and Family Planning Commission,special quality control was carried out on the key items filled in on the medical record based on the actual situation of the hospital.Results Among the 330 critically ill medical records sampled,45.15％had defects,among which 56.38％had defects in the first page of medical records,and 25.50％had defects in the course of disease.In the first page of medical records with the high-est rate of defects,the most common defects were the missing and wrong filling of the basic information on the first page,which accounted for 28.57％of the total number of defects,followed by the missing filling of the transferred departments,11.90％of the total number of information defects in the first page of medical records,and 10.71％of the total number of errors in filling in the intensive-care unit records and in choosing the main diagnosis were equal.Conclusion The defect content of critical medical record is concentrated on the information of the first page of medical record,the course of disease,the record of discharge(death),the informed consent and the authorization letter,it is suggested that we should strengthen doctors'legal awareness,optimize the function of information system,strengthen the coordination between departments,strengthen the training of medical record writing and pursue the responsibility of rewards and punishments,strengthen the management of the quality of critical pa-tients'medical records,and improve the overall quality of medical records.
