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| Research on the status quo of medical record quality and the influencing factors of unqualified rate in a hospital |
| Yin Yuhua1, Wu Huatun2, Zhu Jianqian2 |
1 Chengbei Quality Management Department, Affilated Hangzhou First People′s Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China;
2 Hubin Quality Management Department, Affilated Hangzhou First People′s Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China |
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Abstract Objective To study the current status of hospital medical record quality and the influencing factors of unqualified rate, explore measures to improve the medical record quality, and provide a theoretical basis for the hospital to improve the medical record quality. Methods A stratified random sampling method was used to sample 997 medical records from January to December 2020 in a tertiary general hospital in Hangzhou. SPSS 21.0 was used to analyze the data, and chisquare test and logistics regression analysis were used to analyze the influencing factors of the unqualified rate of medical records. Results The unqualified rate of medical records in the hospital was 11.93%, and the top three defective rates of medical records were the course records (33.00%), the admission records (31.62%), and the first page of the medical records (23.20%). The risk of unqualified medical records in the surgery department (OR=32.475, P＜0.001) and in the department of obstetrics and gynecology (OR=17.428, P＜0.001) was higher than that in the internal medicine department, and the risk of unqualified medical records in other departments was lower than that in the internal medicine department (OR=0.028, P＜0.001 ). Patients hospitalized for more than eight days had a higher risk of unqualified medical records (OR=24.267, P＜0.001), the risk of unqualified medical records with surgery/operations was higher than that without surgery/operations (OR=0.176, P＜0.001), the risk of unqualified medical records for rescue and difficult/death cases was higher than that for without rescue or difficult/death cases (OR=0.011, P<0.001), the risk of unqualified medical records for nonsingle disease management was higher than that for single disease management (OR=11.128, P＜0.001), and the risk of unqualified medical records of non-clinical path management was higher than that of clinical path management medical records (OR=13.840, P＜0.001). Conclusion The qualification rate of medical records needs to be further improved. The quality control of key departments and key medical records should be strengthened in terms of the quality control of medical records, to further promote the management of single disease and clinical pathways, and improve the quality of medical record writing.
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Received: 10 May 2021
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