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| Comprehensive analysis of 120 front sheets of death medical records |
| Wang Xiaocheng, Chen Hua, Qiao Xinna, Wang Meiling |
| Department of Medical Record Management, Shanxi Provincial People′s Hospital, Taiyuan 030012, China |
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Abstract Objective To analyze missing items and scoring of front sheets of death medical records , in order to improve the quality of medical records and strengthen quality control. Methods One hundred and twenty front sheets of death medical records from January to December in 2016 were checked according to the quality criteria of Hospital medical record home page data published by the National Health and Family Planning Commission, and the differences of front sheets between the internal medicine and surgery were compared. Results Many missing items of front Sheet of death medical record home page were found. The whole complete rate was 90.00%. General score was 90.68±4.71 points. Medical records rated as best and good accounted for 5.8% and 51.7% respectively. The rating had no difference between internal medicine and surgery. Conclusion The quality of front sheets of death medical records was poor. Various methods should be taken to strengthen staff training, improve the understanding of the knowledge of the medical record home page, and promote quality improvement, so as to ensure the quality of medical information and medical safety.
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Received: 12 June 2017
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