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| Defect analysis on the first page of ambiguous medical records in a hospital in Guangzhou |
| Liu Sha, Liu Junfeng |
| The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510000, China |
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Abstract Objective To find out defects of the first page of medical records, and improve the inclusion rate and accuracy rate of medical records by analyzing the ambiguous (QY) medical records in the DRGs system.Methods Parts of QY medical records from a hospital in Guangzhou in 2019 were selected to evaluate the defects of medical records from the following aspects: whether the main diagnostic codes were correct, whether the surgical operation codes were correct, whether the main clinical diagnosis was correct, whether the other diagnoses were correctly filled in clinically, whether the surgical procedures were correctly filled in clinically, and whether there were input errors. Results Totally 164 QY medical records were selfexamined, with 73 errors and 59 defective medical records. The error rate of the main diagnosis code was 9.15%, the error rate of the surgical operation code was 6.10%, the error rate of the clinician′s main diagnosis was 6.10%, the error rate of the clinical omission of other diagnosis was 10.37%, the error rate of the clinical operation was 2.44%, and the error rate of the input was 10.37%. The causes of QY medical record included: the defect of the clinician′s main diagnosis/operation filling, the coding error of the main diagnosis/operation, and the incorrect input. Conclusion Regular analysis of QY medical records can help medical record information managers find possible defects in the quality of home page data and normalized training for physicians and coders can improve the enrollment rate of medical records and the quality of home page data of inpatient medical records.
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Received: 17 June 2021
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