Objective To understand the current situation and existing problems of hospitals medical record information construction in secondary hospitals and above in Guangdong Province.Methods The data of 179 hospitals at or above the second level were collected from the national medical quality data sampling survey column from 2018 to 2020. The medical record archiving, CA signature, medical record storage and special quality control method on the front page of medical records were collected. The data was organized by Excel 2010 and analyzed by SPSS 25.0.Results
The use of paperless medical record archiving in Guangdong Province increased from 49.72% in 2018 to 56.42% in 2020 (P＞0.05). In 2019, the paperless archiving rate of tertiary hospitals was higher than that of secondary hospitals (P=0.004). The proportion of partial or full CA signatures increased from 34.64% in 2018 to 43.02% in 2020 in Guangdong Province, and the rate increased significantly in public tertiary hospitals. The proportion of paperless or paper-based medical records and electronic/scanning combined in hospital medical records storage increased from 39.66% in 2018 to 53.07% in 2020, showing an overall upward trend (P=0.011). The informationization rate of special quality control on the home page of medical records in Guangdong Province increased from 17.88% in 2018 to 26.26% in 2020 (P＞0.05).Conclusion The personnel training of medical record coding personnel with information related major still needs to be strengthened. The construction of electronic medical record system has developed in recent three years, but the electronic medical record archiving system, CA signature technology and paperless storage technology still need to be further promoted, and the proportion of special quality control on the front page of medical records using informationbased methods is still low.