Research On Influential Factors And Intervention Countermeasures Of The Effect Of Resident In Controlling Quality Of The First Page Of Medical Record

Background:The first page of medical records condenses the entire information of patients, including all index of medical care evaluation, which is valued in medical treatment.According to the ministry of health notice, medical service supervision information should be uploaded to supervision department through Hospital Quality Monitoring System(HQMS), which focus on automatic docking electronic medical record home page data and become the main data source of statistical evaluation index. However, unqualified first page of medical records, such as incomplete information as well as errors of filling in, affect the uploading information by HQMS completely, timely and accurately, and influence the accuracy and authenticity of statistical evaluation.The resident is the principle people to fill in the first page of medical records. To assurance the authenticity of the hospital assessment data, it is essential to evaluate and research on the influential factors and intervention countermeasures that affecting the quality of the first page of medical records scientifically and systemically to promote the quality elevation of home page of medical record. Objective:To analyze the related influential factors affecting the quality of the first page of medical records filled by resident, according to the main problems of electronic medical record home page uploaded by HQMS network; to summarize effective intervention countermeasures, evaluate and determine the effect of quality improvement anterior-posterior of intervention countermeasures; to make for upload electronic medical record home page completely, timely and accurately by HQMS. Methods:According to the instructions for hospital medical record home page(2012 edition) and the principal specification of medical record, the quality of unacceptable first page of medical record uploaded through HQMS straightly from January 1, 2013 to June 30, 2013 were evaluated scientifically and systemically in one hospital.Total residents were investigated by self-designed questionnaires. All data were entered into Epidata 3.1 twice to ensure accuracy. Statistical analysis was conducted using SPSS(version 16.0). The main statistical method is descriptive statistical method. Rate and constituent ratio were calculated by chi-square test. The multivariate logistic regression model was used to evaluate the related factors affecting the quality of first page of medical records. The level of significance was set at p<0.05.According to main problems of the medical record home page and results from questionnaire, we research the influential factors affecting the resident and summary the corresponding countermeasures. Then, we compared the quality of first page of medical record uploaded through HQMS straightly from January 1, 2013 to June 30, 2013 and January 1, 2014 to June 30, 2014. The last, we evaluate continuous quality improvement effect and propose the effective measures to improve the quality of resident medical record home page, so as to realize the medical record home page uploaded through HQMS completely, timely and accurately. Results:(1) The status quo of the first page of medical record filled in by resident in 2013A total of 17638 medical records were uploaded through HQMS network on January 1, 2013 to 30 June 2013 from 22 departments. Among them, the number in obstetric department is 1978 and intensive care department number is 63. The total number of unqualified medical record home page is 4762(27.0%) in 17638. The main problems existing in are missing items(42.4%), code error(27.4%) and uncorrected diagnose(26.7%) and non-standard write(3.5%).(2) The quantitative analysis and qualitative analysis results of the influential factors affection the quality of medical record home page filled in by residents287 valid questionnaires were returned from all the 302 distributed questionnaires. The response rate was 95.0%.The quantitative analysis results were that chief resident and resident who satisfies for the incentives and penalties had higher quality medical record home page than not.The qualitative analysis results shown the reason effecting the quality of the first page of medical records filled by residents were as follows : deficiency of responsibility, unclear conception, unfamiliarity of main points, imperfect evaluation systems, poorly service level of information platforms, absent of ring-joint quality controls, retardation and unitary of management.(3) Interventional measures adopted by the hospital administratorsHospital managers and frontline staff should be aware of the importance of the quality of medical record home page, learning the related knowledge, completing the evaluation systems, persistence in the chief resident regime, improving the regimens of access appraisal of clinicians and incentives system and enhancing the information platform service. Furthermore, the administrators should be execute multiple quality controls such as multi-level quality control, quality control aspects, terminal QC and other methods to supervise the quality of medical record home page.(4) The comparative results of quality of medical record home page filled in by resident anterior-posterior continuous quality improvement1) The rate of unqualified medical records uploaded through HQMS was 27.0% on January 1, 2013 to 30 June 2013 before continuous quality improvement. But the rate was 3.4% on January 1, 2014 to 30 June 2014 after continuous quality improvement.2) The average missing rates were 33.6% before continuous quality improvement. However, the rates were 5.3% after continuous quality improvement.3) The average main error rate of uncorrected diagnoses was 14.92% before continuous quality improvement. However, it was declined to 3.3% after continuous quality improvement.4) The average error rate of code of disease and operation was 10.4% before continuous quality improvement and 3.06% after continuous quality improvement.5) The average of other error rate was 3.91% before continuous quality improvement and 1.22% after continuous quality improvement. Conclusion and proposition:Hospital administrators and frontline staff should be aware of the importance of the quality of medical record home page, learn the related knowledge, adopt multiple assessments, persist in the chief resident regime, improve the regimens of incentives system, enhance the information platform service and execute multiple quality control methods to contribute to the elevation of quality of the first page of medical records.