Medical Records Basic Specification (trial), The Implementation Of The Current Situation And Countermeasures

ObjectFrom theoretical and empirical research, this study integrated application of qualitative and quantitative research methods, clearly defined the function of medical records and the role and value of "Basic norms of medical records (Trial)" by the literature review and expert consultation. based on this, the quality of medical records at hospital as the starting point, problems of "norms" in the implementation process were studied through multiple levels and systematic understanding and analysis in the country, Shanghai, and a specific region, besides, the influencing factors of "norms" were demonstrated, which helped to put forward the corresponding countermeasures and suggestions.MethodFrom theoretical and empirical research, this study integrated application of qualitative and quantitative research methods, made the quality of medical records as entry point, and clearly defined the function of medical records and the role and value of "Basic norms of medical records (Trial)" by the literature review and expert consultation; made an investigation of the content and the status quo of implementation of "norms" across the country, city of Shanghai and Jinshan District in Shanghai; set up and managed a database by EXCEL, and made statistical analysis by the application of SPSS 13.0 and the corresponding statistics methods; through analysis of the influencing factors concluded from opinion survey and focus group interviews with medical staff, sonocomial administrators and administrative departments officers, proposed the solution; through the intervention measures, made analysis of the difference in the defect rate of the quality of medical records between intervention objects and non intervention objects in order to evaluate the feasibility and effectiveness of countermeasures.Results1, the overall defect rate of 4312 medical records on shelf in 72 hospitals, Shanghai was 53.9%, the department topped the overall defect rate table was the surgery (67.2%), followed by orthopedic (65.7%).2, of all 1630 medical records in Jinshan District, the number of non-standard medical records were 894, accounting for 54.8%, from the perspective of departments:the surgery (69.1%), obstetrics and gynecology (56.3%) and medical (45.6%) ranked the top of the overall defect rate.3, the old norms awareness Investigation in Jinshan District contained 126 objects, there are 10 items with higher than 30% error rate. about "who can write the operation record", interviewees who agreed only operators could write accounted for 74.7%; about "the first check room time for attending physician", interviewees who agreed that must be completed within 24 hours accounted for 93.2%; about "completion time for operational record", interviewees who agreed with within 8 hours made up for 97.1%.4, a total of 19 participants involved in the interview consultation; the causes for the medical records defects included 9 Classes and 47 articles, the countermeasures and suggestions for the medical records defects included 8 Classes 51 articles.Conclusions1, the implementation process of "Basic norms of medical records (Trial)" was far from satisfactory.2, the medical staff at all levels of medical institutions were not completely familiar with the "norms" content; the defect points of theoretic knowledge were generally in accordance with the medical records defectiveness according to the safety inspection results. The awareness of "Basic norms of medical records (Trial)" should be further strengthened for medical professionals.3, the function of medical records are:documentary evidence for dealing with the major medical controversy, vital basis for clinical diagnosis and treatment, important teaching materials for clinic, significant materials for medical research, crucial references for community preventive health care, hospital administration and decision-making, as well as quality management. additionally, they have other funcions such as health care insurance reimbursement proof, aiding finance charges and information statistics.4, the role and value of "norms" lied in its scientific, concise, objective recording of the health care process and the transition and outcomes of patients' diseases, which helped to standardize medical records writing of medical staff; resolving patient conflicts, protecting the legitimate interests of both doctors and patients; and lied in the transition of the quality of medical examination from only focusing on medical records terminal quality management system in the past into a multi-link quality control patterns with rigorous quality control management.5, the causes for the medical records defects mainly lied in indifference, weak sense of responsibilites, heavy workload with limited time, lack of legal consciousness, low seniority, not familiar with the normative content of medical staff, and lack of medical quality management, deficient punishment, unsufficient consideration of the practical medical services in"norms" requirements.6 the countermeasures and suggestions for the medical records defects are to enhance legal education and raise their legal awareness; strengthen the training for understanding "norms", and promote awareness level; reinforce the quality control in the formation process of medical records; perfect medical records appraisal standards; improve and strengthen the rewards and penalty mechanism for medical records quality; focus on the the defect-prone aspects of medical records; amend vague or ambiguous regulations in "norms"; intensify the supervision and penalty of medical records.