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| Current situation of the ventilator-related data filling in the first page of the medical records in a tertiary hospital |
| Guo Shunping, Wang Mingxia, Ye Shiyue |
| The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China |
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Abstract Objective To understand the defects of breathing machine use time and related operation name filled in the medical record front page, and put forward improvement suggestions, so as to lay a solid foundation for the performance appraisal and DRG payment reform of public hospitals. Methods Totally 729 first pages of discharge medical records involving ventilator use time and corresponding operation name in a tertiary hospital from January 1, 2021 to May 31, 2021 were selected. The medical records were consulted one by one, and the filling in of ventilator use time and relevant operation name of clinicians and the coding of ventilator operation name of coders were analyzed. The defects were classified and statistically analyzed. Results The defect rates of ventilator use time, ventilator operation name and ventilator operation code were 20.03%, 59.40% and 55.42% respectively; the defects of ventilator use time were mainly wrong filling and over filling, accounting for 48.63% and 43.15% respectively; the filling defect of ventilator operation name was mainly missing, accounting for 67.21%; the coding defects of ventilator operation were mainly missing coding and wrong coding, accounting for 50.99% and 33.42% respectively.Conclusion Strengthening the training of clinicians and coders, establishing a four-level quality control mechanism for data reporting, and realizing the information management of the first page of medical records, can improve the accuracy and integrity of ventilator use data on the first page of medical records.
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Received: 15 October 2021
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