Research On Risk Assessment Of Adverse Events In The Quality Control Of Medical Records

Objective:Evaluate the quality of medical records by the number and the risk of adverse events. Focus on better quality control of aspects and details in medical records, to write a more professional, logical, precise and’zero defect’medical record. Reduce or eliminate the occurrence of adverse events in medical records to ensure medical safety, reduce medical malpractice, to achieve the maximization of the interests of patients and hospital。Method:Medical records are no longer evaluated by the terminal quality score, but the number and risk assessment of adverse events. Make a comprehensive evaluation of terminal quality and process quality in the quality examination of medical records. Pay attention on terminal quality, and more on process quality control. Evaluate the quality of medical records by adverse events and risk assessment。Results:After calculating the number and risk assessment of adverse events by randomly selected terminal medical records and process medical records during2009-2011, the statistical data shows that P<0.01. It has indicated that the overall incidence of adverse events in medical inter-annual decreasing, there is a very significant difference, proves that the medical evaluation method is feasible。Conclusion:Evaluate the quality of medical records through the number and risk assessment occurring in adverse events. With the risk of adverse events evaluating carried out and inspection enhanced, the medical records’adverse events declined year by year. It is proved that evaluate the risk of adverse events is an effective way to reduce the incidence and one of the most important measure for continuous improvement of medical quality。...