Study On The Intervention Evaluation Of The Home Page Of Inpaient Medical Records

ObjectiveThis study evaluated the quality of the home page of the inpatient medical record in a top three hospital in anhui province,find out the defects in the home page of hospital records.The influencing factors of the defects in the home page of inpatient medical records were analyzed from multiple perspectives,and pointed out the improvement measures and suggestions,to provide a reference for the quality management of the home page of hospital medical records,improve the quality of the home page of hospital records.MethodsThrough the quality management of the home page of the inpatient medical record of a top three hospital in Anhui province,compared with the quality of the home page of hospitalization records in the same period last year,to evaluate the quality of the home page of hospital records before and after management.At the same time,the literature review method was used for questionnaire survey,100 physicians were randomly selected to collect the questionnaire data on the cognition of the home page of medical records and the satisfaction of the quality control management of the home page of hospital records.Epidata3.1 was used to input the questionnaire and SPSS17.0 software was used for statistical analysis.Chi-square test and binary logistics regression analysis were used for statistical description,through the method of brainstorming and root cause analysis to find out the factors influencing the quality of the home page of hospital records,put forwardscientific and reasonable countermeasures and suggestions.ResultsA hospital in Anhui province has implemented quality control measures on the home page of inpatient medical records since July 1,2019,1 solstice,July 2019,September 30,2019,according to Anhui province hospital records home page quality assessment evaluation table "to score,among them,324 medical records had defects on the front page,the defect rate of the home page of medical records was 32.40%,the home page of unqualified medical records was 153 copies,The defect rate was 15.30%.Main distribution of defects:Basic information defects accounted for 30.95% of the total defects,Diagnosis and treatment information defects accounted for 33.62% of the total,Information defects in hospitalization process accounted for 3.36%,Anhui page defect 32.07%.After the hospital implemented the quality control management measures of the home page of inpatient medical records,the number of the home page of defective medical records and the number of the home page of unqualified medical records decreased significantly,the declines were61.66% and 63.92%,respectively.This paper analyzes the influencing factors of filling in the home page of inpatient medical record from four aspects: personnel,software and hardware environment,management and functional departments of the hospital,Mainly manifested as:Medical personnel are not familiar with the specification of the home page of medical records,weak sense of responsibility;Information systems cannot be Shared in real time,no logic check and other related procedures,medical records related to the data;Hospital management methods are backward,single form of quality control;The incentive mechanism is not sound,lack of relevant training,the quality control work is not comprehensive enough.ConclusionThe quality control and management measures of the home page of medical records implemented by a hospital in anhui province have achieved certain results,but there is stillroom for further improvement.beside,The focus of quality control and management in the home page of medical records should be changed from post management to pre-and in-process management,Improve the sensitivity to defects in the home page of medical records,it can effectively reduce the home page of medical records repeated modification behavior.