摘要
Abstract
Objective Through the quality control analysis of the homepage of medical records,the causes of problems were identified,improvement strategies were formulated,and the quality of thehomepage of medical records was improved.Meth-ods A total of 5 632 discharged medical records from January 1,2024 to May 31,2024 were randomly selected from Zhucheng People's Hospital,and 37 quality controllers conducted quality control and statistics according to the homepage of inpatient medical records project checklist.The quality control included two major parts,namely,the patient's basic information and hospitalization diagnosis and treatment experience and information,with a total of 46 items.Results Among the 5 632 ran-domly inspected inpatient medical records,there were omissions,blanks,and errors,distributed in basic information category D(49.99％),inpatient diagnosis and treatment information category A(15.87％),and inpatient diagnosis and treatment information category D(15.2％).Among them,the defects of basic information category D were mainly related to the workplace,address,occupation,current address,household registration address and postal code,address,and telephone number;the defects of inpatient diagnosis and treatment information category A were mainly due to the omission of other diagnoses and the incorrect selection of the main diagnosis;the defects of surgical information were mainly due to the incorrect selection of the main surgical operation(7.63％);the defects of inpatient diagnosis and treatment information category D were mainly related to the medical team leader,days of level 2 and level 3 nursing,and quality control nurses.Conclusion The quality control found that there were many defects in the homepage of medical records,and it was necessary to strengthen the training of personnel in various links,continuously improve the quality control management of the home-page,and strengthen the construction of information tech-nology means.关键词
病案首页/质量改进/培训/信息化建设Key words
Medical record homepage/Quality improve-ment/Training/Informatization construction分类
医药卫生
