Improvement And Optimization Of Hospital Record Management Under Reorganization And Development

Objective With the development of society,the continuous advancement has been making in China’s Medical and Health Service and people’s legal awareness.The demand for medical records has gradually increased,whether in the quality or the timeliness.At the same time both copying and borrowing have also raised higher requirements.Medical record is a detailed record of the medical history of the patient,which contains the course of the disease,the treatment,and the medical expenses.The quality of the medical record is an important indicator reflecting the medical,scientific research,teaching and management level of the hospital^[1].The recovery of medical record is the first and basic step in management^[2].The quality of its work directly affects the timeliness,accuracy and reliability of statistical reports.Only high-quality medical records can extract valuable data for the using of hospital leaders^[3]Method This study is mainly based on the review of secondary hospitals and the establishment of tertiary hospitals,based on the"Secondary General Hospital Accreditation Standards（2012 Edition）",and the"Tertiary Comprehensive Hospital Accreditation Standards Implementation Rules（2011 Edition）"In order to meet the requirements,the PDCA（play,do,check and action）cycle method combined with expert interviews and questionnaires,has been used to improve the management of medical records,especially in the quality,that is to increase the rate of Class A,to reduce the incidence of Class B,and to avoid the occurrence of Class C.Using the PDCA cycle method.Find out problems that need to improve,select improved topics,set up quality improvement teams,clarify current processes and specifications,find up the latest knowledge and useful information,set goals to analyze the difference between current status and goals.Choose a plan to improve the process,develop an action plan and data inspection plan,implement the stage,check the improvement,standardize the process,consolidate the improvement results or find further improvement space[4].Put forward targeted solutions and measures,and set goals:1 After the patient is discharged from the hospital,the in-patient medical record will be recovered within 90 working days to reach 90%of the case,in order to further realize the“Secondary General Hospital Evaluation Standard（2012 Edition）”4.23.2.6 After the patient is discharged from the hospital,the in-patient medical record will be recovered within 90 working days after the medical record is recovered.2 to achieve a significant improvement in the quality of medical records,the rate of Class A medical records reached more than 90%,in order to further achieve the Secondary General Hospital Accreditation Standards（2012Edition）"4.23.4.2 case rate of 90%,no C-level medical records and efforts.Compare the changes and evaluate the effect in recovery rate and quality before and after PDCA cycle.In order to move into the new hospital district in May 2020,the medical record room can quickly adapt to the requirements of tertiary hospitals,improve the quality of hospital medical records,provide a more reliable reference for hospital development and leadership decision-making,improve medical quality management level,and achieve sustainable improvement of quality.In this paper,using the medical record management system in the HIS system,a statistical analysis was conducted on the medical record recovery time of a patient discharged from a hospital in Nanjing from July 2018 to June 2019,and the patient was discharged from the hospital during the year.The medical records were reviewed one by one according to the"Jungian Provincial Medical Record Writing Specification"and the"Inpatient Medical Record Score Table",and various indicators were analyzed as the data source of this paper.Comparative analysis took the medical record recovery rate and quality of recovery from July 2017 to June 1818 in the year before the PDCA cycle.（1）Adopting the PDCA cycle method for the recovery of medical record management and the quality of medical record management,gradually improving the recovery rate of medical records and the quality of medical record recovery.（2）Literature review method:Using famous Chinese or foreign databases to search theories,methods and research results of quality monitoring and evaluation of medical records.（3）Questionnaire survey method:A questionnaire survey was conducted among resident doctors,department quality control doctors,department head nurses and office nurses to find out the reasons that affect the time limit of medical record recovery and the quality of medical records.（4）Expert interview method:face-to-face interviews with the heads of 24 departments and the heads of large medical treatment groups in the hospital.How to improve the quality of medical records and improve the rate of medical records of Class A can not be separated from the management of departments and the quality of departments control.Results The recovery rate before and after the PDCA cycle was compared.The results showed that the average recovery rate of 3 days from July 2017 to June 2018 before the implementation of PDCA cycle was 41.18%,the recovery rate of 5-day medical records was 66.52%,and the recovery rate of 7-day medical records was 78.20%.The recycling rate was 21.80%.After the implementation,from July 2018 to June 2019,the average 3-day recovery rate was 70.32%,the 5-day medical record recovery rate was88.87%,the 7-day medical record recovery rate was 97.68%,and only 2.32%of the medical records were recovered over 7 days.This achieves a 7-day recovery rate of 90%,which is a practical basis for achieving a 90%filing rate of 3 working days.Comparing the changes of medical records before and after the implementation of PDCA cycle,the average grade A case rate from July 2017 to June 2018 was 76.50%,the average grade A case rate was 90.20%after the implementation,and the B case rate was 23.13.The percentage was reduced to 9.78%,and the Grade C case was further reduced.The number of C-level medical records before the implementation was reduced to five C-level medical records after the implementation.The quality of medical records has been significantly improved.According to the"Inpatient Medical Record Score Table",the medical records are mainly divided into the medical record home page,admission records,disease record,discharge record,auxiliary examination,medical order and consent form.After scoring analysis,the medical record problem mainly exists in the medical record.The home page,the course of disease records,and the auxiliary examinations and medical orders are three,which account for 80.42%of all problems.Among them,the medical records accounted for 37.02%,the disease record was 10.51%,the medical order and impact report was 32.89%,and other problems accounted for 19.58%of all problems.Comparing the completion rate of the first page of the medical record before and after the implementation of the PDCA cycle method,it was found that the pass rate of the first page of the medical record before the implementation of the PDCA cycle was 90.8%,and increased to 94.02%after the implementation,an increase of 3.22 percentage points;After the implementation of the PDCA cycle,the pass rate of nursing documents was significantly improved（P<0.05）.The defect rate of the course of disease recording before and after the PDCA cycle was compared.The results showed that the defect rate of the disease record was significantly reduced after the PDCA cycle was implemented（p<0.01）.The preoperative examination and the defect rate of the doctor’s defect were compared before and after the implementation of the PDCA cycle.The PDCA cycle method had an auxiliary examination and a doctor’s defect rate of 35.2%,and fell to 10.3%after implementation.After the PDCA cycle,the clinician’s satisfaction with the case office staff was significantly improved（P<0.05 or JP<0.01）.Among them,the clinicians’satisfaction with the work attitude,work efficiency,communication ability,coding accuracy rate,and the correct rate of medical records of the nurses in the case were significantly improved（P<0.01）.The survey shows that the implementation of PDCA cycle can improve the quality of medical record management,improve the work efficiency of medical records management personnel,improve the relationship between clinical departments and medical records rooms,and improve the importance and subjective satisfaction of clinicians on meConclusion By comparing the recovery records and quality of medical records from July 2017 to June 2018 and from July 2018 to June 2019,it was found that the PDCA cycle method is beneficial to improve the quality of medical records.However,there is still a big difference in the assessment requirements for tertiary hospitals.It is recommended to further strengthen the training in and out of the hospital and continuously improve the professional level of medical staff,especially the ideological understanding,the recognition of the importance of medical records;the innovative working mode,the establishment of continuity.Quality improvement team to enhance the enthusiasm and responsibility of the case management staff;improve the work system,formulate relevant work processes,clear division of labor,responsibility to people,clear rewards and punishments,increase supervision;support of external information equipment,according to various departments Requires constant updating of information systems and hardware devices.