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《Contemporary Medicine》 2017-13
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Specialized subject hospital health care medical records quality present situation investigation and analysis and improvement strategy

Lin Hua-jun;Li Yan-ping;Department of Medical Education, The Third Affiliated Hospital of Second Military Medical University;  
Objective By investigating specialized subject hospital health care medical records quality, analysis the reason, countermeasures are put forward. Methods Randomly selected 2014 health care medical records of 530 hospital, fee standards and health policy and regulations in Shanghai, on the basis of the hospital medical records to check item by item, type of statistical analysis is not reasonable, and the improved 530 and2015 health care medical records were analyzed. Results The selected 530 discharged medical records in the unqualified case detection rate was17.55%(93/530), including unreasonable charge proportion is higher, about 49.5% of the unreasonable medical record number. Improved health care medical records of 2015 unqualified medical records before detection rate(6.60%), significantly lower than the improvement in 2014 unqualified case detection rate(17.55%), the difference was statistically significant(P 0.05). Conclusion The health care work should pay attention to health care quality of medical records, with health care medical records as the gripper, the implementation of health policy, protect the interests of the people, to reduce health care to refusal of payment.
【CateGory Index】: R197.5
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