Application Of The Quality Control System Of The First Page Of Medical Records In The Improvement Of The Quality Of The First Page Of Medical Records

Objective:To explore the effect of the quality control system for the first page of medical records on improving the quality of the first page of medical records and the problems existing in the process of using the system,to lay a foundation for the hospital to improve the quality of HQMS network direct report and realize the DRGS medical insurance payment,and to provide reference and practical guidance for promoting the application of information technology in the quality improvement of the first page of medical records.Methods:1.Take a case of a third-level,first-class hospital in Hunan Province and make statistics of all the homepages of HQMS network direct medical record reports of the hospital during the period of before the use of the medical record front page quality control system(solstice was discharged on July 01,2018 and December 31,2018),during the trial of the system(solstice was discharged on March 01,2019 and August 31,2019)and after the use of the system(solstice was discharged on January 01,2020 and June 30,2020).Analysis report is unqualified for the first time all of the information of the medical record home page data,according to the personal information,process information,treatment in hospital,cost information four categories,a total of 18 entries to statistical classification,attempts to compare quality control system before using,trial and after the quality control system using different departments(internal medicine,surgery,obstetrics and gynecology and pediatrics)of the medical record home page fill in quality,To explore the application effect of the quality control system on the first page of medical records in different departments.2.After using the quality control system of the first page of medical records(discharge from hospital from January 01,2020 to June 30,2020),80 copies of the first unqualified and qualified medical records on the HQMS network direct report were randomly selected(all required to be written by different doctors),the 160 resident doctors who filled in the first page of medical records were investigated by using the self-made questionnaire on the use of quality control system of the first page of medical records.3.Conducting in-depth interviews and consultations with Hospital Management Personnel,heads of functional departments,staff of the medical records office and technical personnel of the quality control system,and exploring the root causes leading to the failure of the first page of the HQMS direct online medical report,and find an effective strategy to solve the problem.Results1.Before,during and after the system debugging,the number and qualified rate of HQMS network direct report medical records were:45599,67.91%;49055,76.87%;38287,99.16%.After using the quality control system,the total qualified rate of the first page of the medical records was increased by 31.25%,and the qualified rate of the treatment information was increased by 27.95%,while the cost information was decreased slightly(increased by-0.20%)The first five items with the most obvious improvement effect were: Coma Duration(17.81%),diagnostic coding range(6.69%),out-patient and emergency diagnosis(3.03%),identity card information(2.35%)and neonatal weight(1.95%)In addition,the eligible rate of the 4 items of the newborn’s weight in hospital,the duration of coma due to craniocerebral injury,the diagnosis of birth injury and the delivery integrity have reached 100% after using the system.However,the 4 items of name of hospital transfer or community transfer,charge and record of operation,range of pathological diagnosis,blood type and RH test showed the rebound phenomenon that the qualified rate decreased obviously in system debugging.2.After the quality control system was used in different departments,the qualified rate of the first page of medical records was significantly higher than that of the system trial.In the system trial error rate is the highest department of Obstetrics and gynecology,the fewest department of pediatrics;After the use of quality control system error rate is the highest department of internal medicine,the fewest department of pediatrics.The rate of improvement from high to low was as follows: Gynecology and obstetrics(up 45.81%),internal medicine(up29.71%),surgery(up 27.79%)and pediatrics(up 10.30%).3.There are some errors in the information of the first page of medical records,such as missing,wrong and inconsistent information.The single factor analysis of the quality of the first page of the medical records of the residents showed that there were significant differences among the four factors: The age of the ineligible patients,the training frequency of the quality control system,the training effect of the quality control system and the mastery degree of the quality control system(P﹤0.05;The results of logistic regression analysis showed that the older age of resident,the less training times of using quality control system were the important factors influencing the quality of filling in the first page of resident medical records.4.The main reasons for the failure of the quality control system are that the quality control rule base is not perfect,the quality control system or the computers used by residents are not updated in time.100% of the residents are willing to use the first page quality control system,and 88.75% of the residents think the first page quality control system is very effective 97.50% of the residents think that the quality control system can improve the qualified rate of the first page of the medical record obviously,and 95.63% of the residents think that the quality control system of the first page of the medical record is very convenient to use and has the Promotion Value No resident held a negative attitude to the front page quality control system of medical records.Conclusions1.The quality control system of the first page of the medical record can effectively improve the qualified rate of the HQMS net report and the quality of the first page of the medical record.2.The first page of the medical record quality control system has been unanimously approved by the resident.All residents of the first page of the medical records quality control system,the use of the effectiveness,ease of use and the value of promotion are positive evaluation.3.The quality control system of the first page of the medical record has some defects.It is an important measure to improve the rule base of the quality control system of the first page of the medical record and to update the quality control system and the computer in time.