Study On Quality Monitoring System Of Medical Records For Clinical Pathways

ObjectiveTo build a medical record quality monitoring system for the clinical path according to the questionnaire method, the insider interview method, and the delph method based on the literature analysis, empirical investigation, and existing experience. The study including the scientific monitoring methods, processes, content, organizations, institutions is in order to standardize the clinical diagnosis and treatment, and to improve the quality of medical records of the clinical pathways, so that the makers of clinical pathways can make better use of the medical record information, and then reach the purpose of standardization of the medical records of clinical pathways.MethodUsing quantitative research and qualitative research method of combining. The main methods include:(1) Literature research method:using the Chinese and foreign well-known database and the search engines to retrieve the information of the theories, methods and findings of clinical pathway and medical record quality monitoring.(2) Scene investigation:using the questionnaire method and the insider interview method to analyse the application effect and the existing problems of the medical record writing and quality monitoring.(3)Mathematic statistic method:using the descriptive statistic method to analyse the situation of the quality of medical records’ writing and quality monitoring. (4) The delph method:using the delph method to lay down the content of medical record quality monitoring.Results(1) Using the questionnaires method, the insider interview method and literature research method we learned that:there is no medical record quality monitoring system now. The doctors and medical records managers know little about clinical pathways, and they are also not familiar with the standards of medical records and ICD-10. Currently most hospitals used the medical records quality monitoring of four levels. But there are still problems existing. Firstly, less attention were payed to control the link quality. Secondly, the time limit of medical records’writing can not be monitored. Thirdly, the connotative quality of medical records have not been controlled in the medical departmental. Fourthly, the monitoring should be strengthen, and the rewards and punishment is not strict, also the monitoring effect is not obvious.(2) Using acute myocardial infarction for example, made16rules clinical path-oriented medical record quality monitoring specific content under five dimensions including death records, hospital records (or re-admitted for the record), course record, doctor’s advice single and supporting checklists through two rounds’Delphi method, and then add them to the standard of medical records quality assessment score.(3) Determined the organization, staff and their duties of the medical record quality committee. Put forward the methods, processes, reward and punishment system and scoring criteria for the medical record quality monitoring of clinical pathways with emphasis on the responsibilities to each person and control point. Built a complete medical record quality monitoring system for clinical pathways.Conclusion (1) Currently the hospital’s medical record quality control is ineffective. The doctors and medical records managers are lack of understanding on the importance of the clinical pathways, the medical records quality monitoring and related standards. The study on quality monitoring system of medical records for clinical pathways is very necessary.(2) Put forward several suggestions to improve the quality of medical records of the clinical pathways:to strengthen the training of clinicians; to improve the professional qualities of the medical record managers; to develop the quality control standards of medical records of clinical pathways.