Construction And Application Of Two-level Randomized Blind Model In Medical Records Quality Control

With the development of the times,the role and importance of the medical records has become increasingly prominent.Good quality of medical records can not only promote the development of medical treatment,teaching and scientific research,but also play an important role in the payment of medical insurance,insurance reimbursement,legal documents,DRGs promotion and so on.However,the current medical records quality can not fully meet the new requirements of social and medical development.The mainstream quality control methods of medical records also has some limitations,lack of corresponding responsibility to ensure the effect of quality control.ObjectiveThe current medical records quality control work is vulnerable to be disturbed,and the work quality can not be guaranteed.This project is oriented to improve the quality of medical records and connotation construction.Through designing the two-level random-blind mode,setting up scientific records quality control methods and the mechanism to guarantee the implement of corresponding responsibility,we aim to optimize medical examination,improve the supervision,creat a fair and open environment for quality control.Meanwhile,with the medical quality control mode of responsibility,normalization,we aim to promote clinical departments to constantly improve the quality of medical records and medical service.On the other hand,combined with the requirements,we design the software of medical record quality control platform and information publish to improve work efficiency,unified the operation standard,optimize medical rectification process,standardize data generation,reduce the bias caused by human factors.MethodsBased on the literature review,brainstorming and other methods,we acquire the current situation of domestic medical records quality and the mainstream methods of medical record quality control and find out the defects and deficiencies.Combined with the practical experience of a certain medical institutions,we build a new method of quality control based on the mechanism of guaranteing the implement of corresponding responsibility.Through restructuring the work team,adjusting the division of tasks and working time,evaluating attendance,sampling the results,handling feedback and appraising performance,we optimize team functions,strengthen the responsibility to implement and build a fair environment of quality control.At the same time,in order to improve the quality control of medical records,we ally with the software company to design the software of hospital medical record quality control operation platform and information release system.Finally,we select a three grade hospital in Jiangsu province as the pilot,and test the operation effect of the method and software and puts forward the rectification opinions,ultimately achieving the intented purpose.Results1.After the implementation of the new quality control mode,it was found that the overall Grade A case rate increased from 90.58% to 95.6%(P <0.05)in January 2017,the number of Grade A case less than 90% falls from 13 to 5(P <0.05),severe defect records from 4 cases to 0 cases,and all the medical records archiving timely,compared with the quality of medical records in January 2016.2.Through analyzing the general defects,we find that the duration record and the basic rules of auxiliary examination are common high incidence area in the terminal medical records of the internal and external medicine department.The duration record and admission record are common high incidence area in the link records of the internal and external medicine department.The duration record is a common high incidence area for both terminal and terminal medical records.3.The analysis of the connotation quality shows that the "defect category" problem mainly focuses on "action improper" and "being passive"."action improper" accounts for a large proportion.The problem of "defect consequence category" is mainly focused on "general infringement of economic interests".4.Based on the work assessment,it suggests that after the hospital’s targeted training,inspectors can be competent with quality control work and complete the task successfully.However,there is still some room for improving.Conclusion1.We improve the rate of grade A medical records,reduce the rate of deficiencies and grade B medical records and speeds up the return of the medical record correction.In addition,the quality control of the connotation quality is also on the right track,improving the quality of medical records and effectively guiding and standardizing the operation of quality control.2.We cover the shortage of the team members,relieve the work pressure,optimize the professional structure and labor division,improve the efficiency,thereby enhancing the mission implementation scientifically.3.we create the right environment to make a person be responsible,dare to be responsible,must be responsible for quality control,reduce the interference of human factors and other factors,to ensure the work completed fairly and equitably.At the same time,we construct a closed management path to make feedback prompt,operation order,rectification standardized and improve the work efficiency.The implementation of the quality control mode have found an effective way to solve the problem that the current medical records can not guarantee the quality of work,quality control experts are easy to be unvalued,and quality control work vulnerable to be interfered,improving the quality of medical records.At the same time,under this mode,the requirements for medical institutions’ hardware and software are relatively low,which is worth trying to promote.The implementation of the mode should pay attention to the overall grasp,doing a good job of link quality,refining the connotation of evaluation,taking advantage of information technology,meanwhile attaching importance to education,training and writing,and cultivating culture.