Study On The Present Situation And Countermeasures Of The Quality Of The First Page Of Medical Records In A Major Hospital In Guangxi

Objective: Based on the evaluation of inpatient medical record quality in a hospital in Guangxi,quality of the medical records in a hospital,to find out the main problems of medical records electronic medical records in the home;analysis of influence factors of medical records electronic medical records in home defects;evaluation of the quality management of the existing measures,and from the perspective of targeted the proposed improvement measures,provide the basis for the development and perfection of medical records electronic medical record quality management in hospital.Methods: According to The Guangxi Zhuang Autonomous Region Medical Institutions Medical Record Writing Specification and Management Regulations and National Health and Family Planning Commission writing Medical Record Writing Standard,through the scientific quality management of medical records of Guangxi hospital from September 1,2016 to March 31,2017,make the evaluation system,and it is compared with the same period last year.A questionnaire survey was conducted on 200 residents in the hospital by random sampling.Using epidata3.1 the questionnaire double machine using SPSS17.0 to nput all the data for statistical analysis,mainly using the rate of the chi square test,logistic regression analysis of statistical description,using root cause analysis to find out the influence factors affecting the quality of the medical record in hospital,so as to make scientific and reasonable suggestions.Results: The hospital has taken a series of hospital medical records of medical record continuously measures the implementation of quality management from2016 September to 2017 March from September 2016,the hospital records according to the relevant standards for quality control,sampling a total of 5794 medical records,medical records in the absence of 1975 copies,medical record defect rate was 34.09%,the qualified medical records 90.89%.A total of 3475 missing items,mainly distributed as follows: the basic information of the patients accounted for 21.76% of the error,the diagnosis and treatment of information leakage accounted for about 8.49%,the operation of information leakage accounted for about 29.90%,physician signature errors accounted for39.85%.From the hospital before and after the implementation of continuous quality management in the overall situation of the quality of medical records,medical record number of defects was reduced significantly,a decline of 48.50%,in addition,Department of Obstetrics,Department of surgery,cardiovascular department of spinal bone defects in medical records before this improvement more departments have made great progress in the medical record defect rate was great.Furthermore,there are four aspects of the influencing factors: The lack of supervision of hospital management departments;The hospital management departments to carry out the less training of medical records on the home page;The hospital management departments are not comprehensive enough;The form of quality control is relatively single;Management methods are backward;The ack of awareness of the importance of the first page of the medical record of inpatients;The number of residents participating in the study and training is less;The hardware and software environment of the quality management of medical records in The hospital is still limited.Conclusions: The intervention of the front page of a medical record in a large three grade hospital in Guangxi has achieved certain results,but it still needs further strengthening.In addition,the quality control of the first page of medical records should be shifted from the final quality control to the real time quality control of the running medical records,and the defects of the medical records should be prevented so that the behavior of modifying the medical records can be effectively eliminated.