Study On The Present Situation And The Influencing Factors Of Medical Records Quality Management In The Hospital

Objective:By assuming the writing quality of medical records especially the connotation quality,we tried to find out the defects existing in the medical records and analyze the related factors affecting medical records,thus exploring the comprehensive quality evaluation and management of medical records.Methods:Based on the date of our hospital's monthly check of medical record,6827 medical records of the discharged patients were selected at random from January 1st 2013 to December 31 st 2015,find out the problems existing in the medical records and then using the logistic measures of SPSS software to statistic the influencing factor of terminal medical record.Show the difference of segment quality management between hospital departments by the method of Rank-sum ratio and find out the relationship between segment quality and terminal quality using relevant analysis.Result:(1)6696 medical records was evaluated qualified taking up 98.08% while 131 of which are the unqualified medical records,accounting for 1.92%.The average score of these medical records was 95.16.The total defect quantity of all the selected medical record was 20202.Almost 2.96 defects exist in each medical record.(2)The quantity of unqualified medical record due to line-item veto was 63,accounting for 48.09% in all the unqualified medical records.(3)The main factors influenced the terminal medical records were education and sex.Education was the helpless factor,but sex was the helpful one.(4)Specialized medicine system was better than internal medicine system and surgical system in segment management quality of medical records by the method of Rank-sum ratio.(5)There exist some positive relationship between terminal quality and segment quality in medical records by relevant analysis.Conclusion: The whole quality of terminal medical records was up to the standard during 2013-2015.Whether the terminal medical records was qualified or not depended on clinicians' education and sex.Segment quality contributes to terminal quality in medical records quality management.We should improve the writing skills of medical records by education of medical ethics and strengthen the standard of writing training;Innovative work mode to enhance the vitality of management personnel of medical record;Improve the working model,and promote and perfect the construction of medical quality management team;Strengthen job responsibility and pay more attention to the second level quality supervision of processing the medical record quality control;Set up the multi-approach of management countermeasures to overall planning processquality management.