Study On Status And Impact Factors Of Medical Records Quality In Grade-three Hospital In Xinjiang

Objective: Through the study on medical records quality in the Xinjiang hospital, we can understand the status of the medical records quality and problems of medical records, and analyze the impact factors in the quality of medical records writing. Accordingly put forward the improvement Suggestions and measures, provide a reference basis for scientific of medical records management, to improve the quality of medical record quality and medical treatment. Methods: The study collected Medicare patients hospitalization data for 103148 in 2014 from the HIS system, get the terminal quality control data in 2014, and collected the information such as gender, educational background and professional title from the human resources department, by means of literature, expert interview, chi-square statistics and Logistic regression analysis method. This paper discusses present situation and factors influencing the quality of medical records, and puts forward some countermeasures and Suggestions to improve the quality of medical records. Results : Out of the 103148 med ical records in 2014, there were 2220 defects.The defect rate of medical records was 2.15%; These main defects included: defect of progress notes(50.70%), auxiliary examination and doctor’s advice(20.79%) and first paper(16.48%). The defect of progress notes mainly included: progress notes had no physician signature(64.03);Consultation records were incomplete(13.38%); Turn records did not reflect specialist content and simple(7.73%).The defect of auxiliary examination and doctor’s advice mainly included: examining reports didn’t mesh with the doctor’s advice or progress notes(58.26%); examining reports didn’t mesh with the basic information of patients(40.68%). The defect of first paper mainly included: missing of superior doctor signature(31.28%); unfilled medical information(29.68%); inaccurate diagnosis(14.44%).Many defects in medical records set in critically ill pat ients and faster turnaround wards. Female physicians medical records writing quality is better than male physicians. High title of physician medical records writing quality is better, and highly educated physician medical records quality is better. The med ical records quality of non-surgical departments is better than surgery department, without transferred quality of medical records is better. The medical records quality of shorter hospitalization is better. Conclusion: There is no serious defect but many problems in the medical records quality of the investigated hospital. Different gender, educational background, title of the medical staff of medical record writing quality difference is statistically significant. C lassification of ward, transferred medical records and hospitalization days have an impact on the quality of medical records. We should strengthen the surgery department, transferred medical records, and long hospitalization medical records writing quality of supervision, and strengthen the training of relevant personnel.