The Problems And Thinkings In The Quality Of Medical Records On TCM Nephropathy

Purpose:The purpose of this paper is to strengthen the quality control of the medical records and improve their quality on TCM clinic nephropathy in order to prevent the medical risk. Mainly through analyzing manifestations of the disfigurement in medical records, the effect of medical records on hospital management, the prevention of medical risk, the paper studied and discussed how to improve the quality of writing medical record, the paper researches and explores the whole course of the quality control of writing medical records (including the front-end quality control, the process control and the final quality management), which not only improves the quality of medical records on TCM nephropathy but also provides a reference for hospital manages to do well in quality control of the medical records.Methods:In the design scope, we randomly got 180 medical records from non surgery comprehensive records of the year 2008 from six medical institutions (above level two) in Qingshan district (in which 1 of Three level of first-class hospital,2 of Three level of second-class hospital,2 of Two lever of first-class hospital and 1 of Two level of second-class). The paper made marks based on《basic standards of writing medical records (try line)》,《standards of writing medical records for institutions of traditional Chinese medicine and integrative medicine》,《Regulations of medical records management for medical institutions》and《standards of medical record quality assessment for hospitalization in Hubei》and appraised the first class medical records, second class medical records and third class medical. It made a statistical comparison on nephrology medical records vs. other non-surgery section first class medical records rates, TCM (Chinese and Western Integrative) nephrology medical records vs. western nephrology medical record first class rate and summarized main defects in medical records of TCM (Chinese and Western Integrative) nephrology and put a focus on analyzing the existing primary problems in TCM (Chinese and Western Integrative) nephrology medical records.Results:The first-class case rate among 6 hospitals is 75.56% with 24.44% second-class case rate and no third-class. The first class medical records of kidney section is 76.67%, and the TCM(Chinese and Western Integrative) is 65%. At present, there are a plenty of problems on medical record writing in part of the TCM (Chinese and Western Integrative) cases, mainly manifesting on the content of the record is not fulfilled in time with accuracy; the whole content of a medical record is not integrity; the basis of treatment based on disease differentiation and syndrome differentiation is not adequate; the writing of reasons, methods and medicine is defective, and objectivity, truth, accuracy, on time, integrity are all has a distance to go.Conclusion:The quality of medical case writing has significance on the effective use on medical records. Medical case writing is a obligatory course for clinical students and it is not easily mastered in a short period of time. As a post-graduate student majoring Chinese and western integrative medicine to improve the quality of medical cases on nephropathy, we should not only have solid theory on it, but also should pay attention to developing the skills of Wang Wen Wen Qie in TCM. Moreover, we should read more on medical record control and learn more about the hospital management in order to adjust to the present method of medical record management and improve our skills in writing it.