Study On Quality Of Medical Records And Its Determinants In A Hospital In Changsha City

Backgrounds:Medical records, including outpatient (emergency) and hospital records, are data deriving from medical actives of doctors such as words, marks, tables, images and pathological slice, etc. Besides honestly recording medical history and care of patients, medical records can directly reflect medical treatment quality, academic and management levels of a hospital. Furthermore, medical records provide preliminary data for clinical treatment and basic research as well as hospital management. Also, it is an important document in protecting the legal interest of both patient and hospital. The improvement of medical record quality is of key importance to reinforce medical treatment quality, which as "hospital lifeline" exerts core competition of hospital. At present, the most of the researches only simply described the defect of medical record, while the causes that lead to defected record were neglected.Aim:The aims of the present study were, on the base of the investigate of the writing quality of medical records in a hospital of Changsha, Hunan, to understand the status and problems of medical records and to analyze the impact factors in the quality of medical records writing.Method:In the all hospital medical records of 23 wards in 2007 in a hospital of Changsha, Hunan, the 5 records o f every ward in every month were random sampled. According the Basic Norms of Medical Writing (Ministry of Public Health,2002) and Medical Treatment Quality Manual of the hospital (2006), these qualities of medical records were evaluated by three medical directors. Data processing:a review of data to ensure that comprehensive information, security and accuracy. SPSS16.0 conducted through data analysis. The frequency, frequency and composition of the data is the statistical description, analysis of medical records of medical institutions in Changsha to write the quality of the current situation and problems。Results:In 1403 hospital medical records,66% wasⅠgrade,27% wasⅡgrade,6% wasⅢgrade and 6% wasⅥgrade. No record was V grade. These major defects included:(1) defect of first page (35%); (2) progress notes (26%) and (3) surgery record (23%). The defect of first page included:(1) unfilled information, such as changes of wards, complicating diseases and transfuse blood kinds; (2) missing of superior doctor signature; and (3) inconsistency between principal diagnosis and hospital record. The defect of progress notes included:(1) ignoring abnormal examination results; (2) inconsistency between doctor's and nurse's record; (3) missing three grades doctor's rounds records in scheduled time. The defect of surgery record included:(1) unfilled regular information; (2) inconsistent with other medical record; and (3) a lack of detailed about surgery process. The present study found that the medical record quality of male doctor and non-surgery ward were better than that of male doctor and surgery ward, respectively. The medical record quality of doctor with high technical title was better than that of doctor with low technical title.Conclusion:There is not serious defect but many problems in the medical record quality of the investigated hospital. Writing quality and grade of the impact of medical factors in the doctor's gender, education, titles and locations of the sections should be strengthened in the lower title of supervision staff and to strengthen the supervision department operation normative work.