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| Effect analysis of quality control in surgical process on improving the quality of perioperative medical records. |
| Jia Huili, Yang Hua, Zhang Juan, Xiao Ming. |
| Changji People′s Hospital, Changji 831100, China |
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Abstract Objective To evaluate the effect of quality control in surgical process on improving the quality of perioperative medical records. Methods Ten percent of the perioperative medical records in 2019 were randomly examined for quality control, and the quality defects of medical records before and after quality control intervention in the surgical process were compared and analyzed. Results The quality defect rates of the 11 medical records in the intervention group were all lower than those in the control group, including power of attorney, informed notice, preoperative summary, preoperative discussion, surgeon′s ward round record, anesthesia visit record, surgical safety check, surgical record, first postoperative course, anesthesia records surgical approval (P<0.01). The top three indicators for improving the quality of medical records were the first postoperative course, power of attorney, and anesthesia visit records, which reduced by 23.95 percent, 16.64 percent, and 15.32 percent respectively. Conclusion Defects in the quality of medical records include inadequate implementation of the core system, incomplete informed notification, and poor quality of medical record writing. The quality of medical records could be improved by strengthening medical record quality control, conducting medical law knowledge training, and strengthening medical record writing quality training.
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Received: 08 September 2020
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