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《Chinese Medical Record》 2018-06
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Filling Quality Analysis of the Discharge Diagnosis of Inpatient Medical Records Front Pages

Zhu Xiaorong;Medical Record Management Department of Boltara Mongol Autonomous Prefecture People's Hospital;  
Objective To analyze the problems existing in the filling process of discharge diagnosisanalyze and conclude and put forward relevant countermeasures.Methods According to the rules in the The Fill in Quality Specifications of Front Pages Inpatient Medical Records(Pr visional) and other pr visions that announced by the National Health And Family Planning Commission and other regulations,the problems of quality defects in hospital medical record home pages on the hospital diagnosis during January 2017 and march 2017 were retrospectively analyzed.According to the completeness,logicality and prescriptive analysis of discharge diagnosis.Results There were 1000 copies of hospital medical record front sheet.51 copies of them existing defect,the defect rate was 5.1%,The number of errors of no complete in the discharge diagnosis was the highest,the error rate is 45.1%.Conclusions The mainly reasons of low complete rata of front pages inpatient medical records are many writers not of departure from the hospital way directly affect the overall accuracy and completeness of the information date.The hospital should strengthen the training of the new hospital medical record front page standardization and strengthening quality consciousness to improve the overall quality of the medical record writing.
【CateGory Index】: R197.323
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