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| Analysis on data quality of medical record front sheet in a hospital in 2017 |
| Wang Xiaoqin, Cui Xuedan |
| Department of Information, Weifang Yidu Central Hospital, Qingzhou 262500, China |
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Abstract Objective To find out data quality defects on patient medical record front sheet (MRFS) through descriptive statistical analysis in a hospital in 2017, and to identify the causes for the problems and suggest remediation to improve the reporting quality.Methods Totally 60 642 in-patient medical records were collected from a hospital in 2017 and 70 items on MRFS were statistically analyzed. The incompletion rate and error rate were calculated.Results The highest incompletion rate and the highest error rate both occur on the item of other information, and a variety of errors present.Conclusion The data quality of MRFS is unsatisfactory. It directly affects the ranking of the performance analysis of hospitalization service of the third-class comprehensive hospital in shandong province. To improve the quality of MRFS, it depends on effort and cooperation from clinicians, network information technicians, and the final medical record checkers.
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Received: 29 May 2018
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