Study On The Status And Management Strategies Of Inpatient Medical Records Quality In A Newly Established Grade-three Public Hospital In Guangxi

Objective:Through the research on the status of inpatient medical records in a newly established grade-three public hospital,the hospital's current medical record defects and medical record quality were included in the performance of the management intervention after the performance appraisal,find the weak links in the hospital management,and propose corresponding improvement suggestions and measures.Methods:A sample of the in-patient medical records of a newly esteblished grade-three public hospital in Guangxi from October 2018 to March 2019 was opened.In the total of 4,767 inpatient medical records,about 70%of the inpatient medical records of each department were extracted by convenient sampling as a research sample.Using the literature research method to sort out the policy system and the quality management of medical records at home and abroad,use the interview method to deeply understand the current status of hospital medical records,the causes of medical record defects and management suggestions,and analyze the quality of hospital inpatient records by using statistical methods in mathematical statistics.The overall situation,T test for the difference between the surgical department and the non-surgical department,the average difference of each medical record defect,the chi-square test to analyze the quality of the medical record into the performance of the management intervention after performance appraisal.Results:1.A total of 2,100 inpatient medical records were detected by random examination of medical records,and the average number of medical records per defect was 0.629.There are different levels of problems in the seven items of inpatient medical records.Among them,there are 573 defects in admission records,and the average number of defects per medical record is 0.172,which is 27.286%.The basic requirements for writing are the least,with 30 defects.The average number of medical records per defect was 0.009,which was 1.429%.The monthly Class A case rates from October 2018 to March 2019 were 58.929%,61.194%,78.116%,87.464%,87.313%,and 87.850%,respectively.2.Compared with the average number of medical records per subject,the number of ICU medical records was 4.619,the number of surgical departments was 0.894,the internal medicine was 0.679,the obstetrics and gynaecology department was 0.284,and the pediatric department was 0.212..The T-test results of the number of medical records per surgical record in the surgical department and the non-surgical department showed that t=-0.510,P>0.05,and there was no statistical difference.According to the department,the three departments with the highest number of medical records per year were 4.619 items in ICU,4.200 items in cardio-thoracic surgery,and 2.157 items in rehabilitation department.3.Before and after the quality of medical records was included in the performance appraisal,the chi-square test results of the grade A medical record were ?2=103.567,and P<0.001.The difference was statistically significant,indicating that the management measures played a role in improving the quality of hospitalized medical records.Grade A medical records increased significantly after quality was included in performance appraisal.4.The interview results of functional departments and clinical departments showed that the hospital's medical record defects were mainly related to personal habits and business level,medical record system,hospital supervision,etc.The management suggestions and countermeasures proposed by the interviewers were to strengthen training and management.Improve the medical record system,functional departments and clinical communication,and display medical records.Conclusion:The quality of medical records was not good at the beginning of the hospital's opening and construction.After the performance appraisal management intervention,the number of Grade A medical records increased,the Grade A medical record rate increased,the medical record quality improved,and the hospitalized medical records were more and more standardized,but the third-grade hospital A was reached.The target case rate is more than 90%,and there is no C-level medical record.It is also necessary to improve the hospital rules and regulations,strengthen the performance appraisal,strengthen the monitoring of medical records,improve the electronic medical record system and template,strengthen the two-level training of the department,and improve the legal awareness of physicians.To allow physicians to fulfill their obligations and to continuously improve the quality of inpatient medical records.