摘要
Abstract
Objective To analyze the results of the quality inspection of the content of terminal medical records in a tertia-ry hospital,summarize the causes of common problems,and propose corrective measures to provide a basis for the efficient imple-mentation of medical record quality management work.Methods Based on Zhejiang Province medical record quality scoring crite-ria,a medical record quality inspection scoring form was developed for the hospital.A total of 7,140 terminal medical records dis-charged from the hospital between January 1,2023,and December 31,2023,were randomly selected for content quality inspection.The discharge rate and major defect occurrence rate of medical records before and after quality improvement were compared.Results After the implementation of corrective measures,the overall qualification rate of discharged medical records increased from 84.76%to 91.38%,and the rate of individual vetoed medical records decreased from 6.07%to 2.32%,with statistically signifi-cant differences(P<0.05).The frequency of major defect issues and major individual veto issues in discharged medical records decreased after the improvement,with statistically significant differences in the two groups(P<0.05).The frequencies of issues regarding the lack of a 72-hour conversation record and the lack of the first postoperative course did not show significant changes before and after the improvement,with no statistically significant differences(P>0.05).After the improvement,the number of medical teams with a twelve-point deduction score≥6 decreased from 28 to 8,with statistically significant differences(P<0.05).Conclusion Many factors can affect the quality of medical record writing.By implementing a series of corrective meas-ures such as strengthening medical record writing training,enhancing the four-level quality monitoring system of medical record management,improving the reward and punishment system,establishing a convenient and efficient communication platform,and strengthening quality management in various stages,the quality of medical record writing can be effectively improved.关键词
终末病历/内涵质量/改进/分析Key words
Final medical record/Connotation of the quality/Improvement/Analysis分类
医药卫生
