| BackgroundIn recent years,the state has issued many specifications for filling in the homepage of medical records,and formulated corresponding policy documents to improve the quality of the homepage of medical records.Only by filling in the homepage of the medical records completely and accurately can we maximize the use of the medical records data.High-quality medical records data plays an important role in the formulation of relevant policies of government departments,hospital management and decision-making,and patient medical insurance reimbursement.However,there are still some cases of omissions and misfills on the homepage of the medical records,which will affect the quality of the data on the homepage of the medical records.Therefore,in order to improve the data quality of the homepage of the medical records,it is necessary to analyze the influencing factors of the quality of the homepage of the medical records,so as to put forward improvement countermeasures.ObjectiveThis study adopts a mixed research method combining quantitative and qualitative research.By analyzing the current situation of filling in the homepage of inpatient medical records in a public hospital in Jinan City,Shandong Province,it identifies the problems existing in the process of filling in the homepage of medical records and analyzes the impact on the quality of filling in the homepage of medical records.factors,and put forward countermeasures and suggestions in a targeted manner.MethodsThis study used the literature research method to sort out the relevant research on the home page of medical cases at home and abroad;the on-site investigation method was used to understand the current situation of filling in the first page of the case of Jinan A Hospital in Shandong Province,and a total of 1928 case home pages of 12 operating departments and 8 non-surgical departments were sampled by the hierarchical group sampling method,and the relevant quantitative information of doctors was collected through the questionnaire survey method,and the main survey was carried out by 178 clinicians on the knowledge and belief of the first page of the case(a total of 178 questionnaires were issued,and 158 valid questionnaires were recovered.The effective recovery rate was 88.8%);qualitative data were interviewed by a total of 11 functional department personnel and clinicians using the purpose sampling method,mainly to investigate the problems and countermeasures in the writing and management of the first page of the case.Epidata 3.1 was used to establish a database for data entry,and chi-square test and binary logistic regression analysis model were used to analyze the influencing factors of the filling quality of the homepage of medical records.From the perspectives of supervision and system,analyze the influencing factors of the filling quality of the homepage of medical records,and put forward countermeasures and suggestions.Data analysis and processing were mainly completed by SPSS 26.0,Nvivol 1.0,Excel2016 and other software.Results(1)Status of filling out the home page of medical records1)Completeness rate:This study conducted quality control on 1,928 medical record front pages from a tertiary hospital in Jinan City,Shandong Province.A total of 287 medical record front pages were incomplete,and the overall completeness rate was 85.1%.Among them,the completeness rate of non-surgical departments was 82.9%;the completeness rate of operating departments was 87.2%;the difference between the completeness rates of operating departments and non-surgical departments was statistically significant(P<0.05);2)Defect rate:457 medical records were defective,the overall defect rate was 23.7%,the defect rate in the non-surgical department was 27.1%,and the defect rate in the operating department was 20.6%.The difference in defect rate was statistically significant(P<0.05);3)Defect type:It focuses on three parts:patient hospitalization information,diagnosis and treatment information,and surgical defects.Among them,surgical defects are the main defects.The frequency of defects is 361 times,and the proportion of defects is 43.7%;diagnostic defects ranked.second,the composition ratio was 39.7%;the patient hospitalization information defects accounted for the smallest proportion,with a composition ratio of 16.6%.(2)The quantitative analysis results of the quality influencing factors filled in the home page of medical recordsA total of 178 questionnaires were distributed and 158 valid questionnaires were recovered,with a recovery rate of 88.8%.Fill in the quality quantitative analysis results on the homepage of the medical record:1)People who do not actively learn the relevant norms of medical record writing have a higher risk of failing the homepage of medical records than those who actively learn(OR=0.231(95%CI:0.072-0.746),P=0.014);2)The risk of unqualified homepage of medical records for those undertaking scientific research tasks was greater than that for those who did not undertake scientific research tasks,(OR=2.745(95%CI:1.14-6.764),P=0.028).(3)The qualitative analysis results of the quality influencing factors filled in the home page of medical records1)Doctors do not pay enough attention and are under great pressure2)Quality controllers are under great pressure3)The information system has poor sharing and imperfect functions4)The incentive system is not perfect5)Single quality control method6)Link supervision is not in placeConclusions and SuggestionsThere are still problems in the filling and management of the homepage of medical records,and further improvement is still needed.(1)There are many defects in surgery and diagnosis on the homepage of medical records,and continuous improvement is required;(2)The function of the medical record quality control system is weak,and it cannot achieve quality control such as surgical operation and diagnosis;(3)The training of medical record writers is being strengthened,but There is still a lack of targeted training for each department;(4)The performance appraisal system related to medical records is unreasonable,and a reasonable reward and punishment mechanism has not been established;(5)The quality control supervision at the department level is not implemented in place,and there are problems of formalized quality control;(6)The quality control of medical records has a single form,mainly manual quality control.In order to further improve the quality of filling in the homepage of medical records,based on the above conclusions,this study puts forward the following suggestions:(1)Pay attention to the quality of filling in the homepage of medical records from the source,strengthen targeted training for personnel related to medical records,and pay more attention;(2)Make full use of information technology to realize intelligent quality control on the homepage of medical records;(3)Improve the performance appraisal system and establish a reasonable reward,punishment and incentive mechanism;(4)Strengthen the supervision of link quality control and realize the whole process management of medical records;(5)Explore a variety of quality control modes to form an effective medical record quality control system. |
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