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| Analysis of 90 ambiguous medical records in a tertiary general hospital |
| He Jianxia, Zhao Jun, Yang Fahui |
| The First People′s Hospital of Shuangliu District, Chengdu 610200, China |
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Abstract Objective To analyze 90 ambiguous medical records in a hospital, summarize the existing problems, and put forward improvement measures, in order to reduce the occurrence of ambiguous medical records. Methods The home page information of discharge medical records of a tertiary general hospital in Chengdu in 2020 was uploaded to the Sichuan health data analysis and decision support cloud platform. After grouping, ambiguous medical records were screened out. Clinicians and coders were organized to classify ambiguous medical records, analyze the causes, and make correction and grouping. Results Among the 90 ambiguous medical records, 36 ambiguous medical records were caused by wrong filling in the first page (including 27 major diagnostic errors and 9 major surgical operation errors); 4 cases of multiple diseases were hospitalized at the same time; 50 copies were with unreasonable grouping rules of DRG grouping device. Conclusion The main causes of ambiguous medical records are that clinicians do not master the main diagnosis and operation selection principles, coders have limited clinical knowledge, and department management is not optimized. In order to reduce the incidence of ambiguous medical records, we should strengthen the standardized training of clinicians, improve the comprehensive quality of coders, and optimize the management of hospital departments.
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Received: 11 August 2021
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