| BackgroundAs a record of the whole process of patients’ medical activities,medical records play an important role in diagnosis and treatment activities,hospital management and so on.At present,the main body of medical records quality monitoring and management is still various medical institutions,but there is still a certain gap between different medical institutions in the completeness of medical records quality management policies and the effect of medical records quality control.With the improvement of patients’ legal awareness and the promotion of medical insurance payment reform,new requirements are put forward for the writing and management of medical records.In this context,in order to improve the quality of hospital medical records and standardize medical behavior,a tertiary general hospital in Shandong Province(hereinafter referred to S Hospital)has piloted the medical records quality control system in some departments since 2013 to monitor and manage the writing quality of operating medical records,and has been implemented in all departments of this hospital since 2014.However,since the implementation of the system,there has been no systematic evaluation of its system design and its impact on the quality of operating medical records.ObjectiveThe purpose of this study is to clarify the background and mechanism of the medical records quality control system in S hospital;Analyze the changes of the medical records quality of the whole hospital and each department before and after the implementation of this system,and comprehensively evaluate the medical records quality control system of S hospital;Analyze the main defects of unqualified medical records in S hospital and explore their causes.To evaluate the operating medical records quality control system and implementation the effect of S Hospital,provide suggestions for its further improvement,and provide reference and comparison for medical records quality management of other medical institutions.MethodsThe quantitative data related to the quality of medical records and operating medical records in this study are from the medical record room of S Hospital,the quality control department of S hospital and the operating medical record quality monitoring system data.The qualitative data came from semi-structured on-site interviews with doctors in clinical departments of S hospital and doctors from other hospitals who came to the hospital for further study.This study adopts a combination of quantitative and qualitative analysis methods.The quantitative data mainly used descriptive analysis method to analyze the changes and trends of the average score and grade a rate of operating medical records before and after the implementation of the quality control system of operating medical records in S hospital;By analyzing the defect details of operating medical records in S hospital,to found that the main problems,problems’ structure and change trend of unqualified operating medical records in this hospital and some key clinical departments.The qualitative data were summarized by thematic framework analysis.ResultsAfter the formal implementation of the quality control system of operating medical records,the average score of operating medical records in S hospital increased from 81.42 in 2014(lack of data in 2013)to 97.67 in 2020;The grade A rate of operating medical records increased from 59.59%in 2013 to 88.76%in 2020.The difference between years was statistically significant.In 2014,the total number of defective items of unqualified medical records in S hospital was 102231,including 83079 single rejection items of class A medical records,with an average of 2.02 defective items per unqualified medical record and 1.64 single rejection items of class a medical records;By 2019,the total number of defective items of unqualified medical records in the hospital will be 41220,including 34923 single rejection items of class a medical records,with an average of 1.6 defective items per unqualified medical record and 1.36 single rejection items of class a medical records.The causes of unqualified medical records can be mainly divided into(1)personal reasons,such as untimely writing due to too many patients and busy work,violating the standard of operation time;Some doctors have insufficient sense of responsibility and quality management,do not firmly grasp the relevant standards of medical record writing,and can not write medical records in strict accordance with the standard requirements.(2)Departments’ reasons,such as inadequate implementation of medical record quality control measures in some departments.(3)Hospital management reasons,such as the hospital’s punishment for the quality defects of operating medical records is mild.The doctors in S hospital have a good acceptance of this quality control system.Among the respondents interviewed in this study,88.89%of the doctors fully accept the system,and 11.11%of the respondents basically accept the v,but the existing problems still need to be solved.The design of medical record quality control system of S hospital is reasonable.While implementing the norms,more detailed specific implementation standards are formulated.Some items have improved the standards on the basis of national and provincial norms,reflecting the requirements of policies and considering the actual situation of the hospital,but there are still some problems in this system that need to be solved.Conclusions and suggestionsThe design of medical record quality control system in S hospital is reasonable and runs well,but the construction of feedback mechanism is not perfect and still needs to be further improved;This system has played a positive role in improving the quality of hospital’s medical records,and its design purpose has been basically realized.Suggestions:(1)Strengthen training and education and improve doctors’ quality awareness.(2)Encourage departments to formulate medical record management regulations and strengthen the monitoring of medical record quality.(3)Give full play to the role of quality control doctors and carry out incentive and assessment.(4)Strengthen the management of training doctors and students,and set up independent accounts for monitoring.(5)Improve the intelligence of running medical record quality control system,monitor more scientifically. |
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