Study On The Countermeasures Of Improving The Quality Of The Information Of Home Page Of Inpatient Record Based On PDCA Method

The home page information of hospital medical record is the patients’concentrated essence of all information in their treating process in the hospital.The home page information of hospital medical record often exists deficiency and leakage,wrong filling and other quality problems.In order to improve the quality of information in this paper,we made evaluation about the current situation of information quality for the home page of hospital medical record in the half of 2015,did a questionnaire survey to all resident doctors in the hospital,did expert interviews that were conducted with members of the Medical Records Management Committee and constituted QC team.We analyzed the factors influencing the quality of the home page information of hospital medical record by using descriptive statistics analysis,returning analysis,unconditioned logistic regression analysis and other methods.In addition,we developed and implemented the intervention countermeasures.It took six months to implement the intervention countermeasures.Six months later,we compared the home page information quality of hospital medical record in the first half of 2016 to that in the first half of 2015 and analyzed these two records.Research results show that:(1)The main influence factors of home page information quality of hospital medical record includes less attention to the quality of homepage,less training,imperfect medical record system,lower inspection rate,small level of reward;(2)After six months of intervention measures implemented,the unqualified rate of filling homepage information in the hospital medical record home page dropped from 29.32%in the first half of 2015 to 10.14%in the first half 2016(χ2=1741.65,P<0.01).Medical record coder for the diseases and procedures coding fraction defective in the homepage of hospital medical record dropped from 9.39%in the first half of 2015 to 5.57%in the first half of 2016(χ2= 157.10,P<0.01).(3)The effective intervention countermeasures includes strengthen hospital management and medical personnel to recognizing the importance to the quality of the information homepage of hospital medical record;strengthen the study and training about the filling of the home page of inpatient medical record information;optimize the information platform service of the home page of inpatient medical records in electronic medical record system;carry out and improve the relevant assessment system on the quality of the home page of inpatient medical records;improve and optimize the reward and punishment mechanism of hospital information on the home page of inpatient medical records.