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Influencing factors of delayed filing of medical records in the internal medicine department |
Gu Yuting, Weng Jun, Peng Zhigang |
The First Affiliated Hospital of Sun Yatsen University, Guangzhou 510080, China |
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Abstract Objective To explore the influencing factors of delayed filing of medical records, and to provide countermeasures for improving the filing rate of medical records within 7 working days. Methods The medical record filing data in the fourth quarter of each year from 2019 to 2020 in a hospital were collected, and the influencing factors were screened by logistic regression analysis. Results Logistic regression analysis showed that the protective factors of delayed filing of medical records were refined medical record management policies (OR=0.341) and moderate number of inpatients discharged by the attending physician per month (OR>21-44=0.371). Risk factors were transfer of departments (OR=1.901), readmission (OR=1.337), operation (OR=1.737), medical insurance of diagnosisintervention packet (OR=1.542), month with long holidays (OR=1.864), great number of inpatients discharged by the attending physician per month (OR>44=1.743), case classification (ORurgent=2.669, ORintractable=1.809, ORcritical=2.487) and longer length of stay (OR>5-12 d=1.659; OR>12 d=2.038). Conclusion Delayed filing of medical records is affected by many factors. Carrying out refined medical record management policies, regulating appropriate workload of attending physicians and focusing on the management of medical records with delayed filing risk factors, can effectively improve the filing rate of medical records within 7 working days.
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Received: 11 June 2021
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