Applied research of archived medical record management in medical quality management / 中华医院管理杂志

ABSTRACT

Objective@#To summarize the impacts of the archived medical record value fund as established by the hospital, on the medical quality management, and propose improvement strategies.@*Methods@#Retrospective analysis was made on 1 149 medical record scoring sheets, and the rate of connotations deducting scores in 197 of such sheets were compared. A statistical analysis was made on the archived medical records, regarding the rate of grade A medical records, defects composition of grade B medical records, the rate of connotation deducting scores, and the ability of the quality control experts (error correction ratio).@*Results@#The archived medical record value fund has pushed up significantly the quality of medical records. For example, the rate of grade A medical records rose step by step from 89% to 95%; the rate of grade B medical records with single-item vetoes fell sharply, a difference of statistical significance (P<0.05); the connotation quality management of medical records was constantly improving, with the rate of connotation deducting scores gradually elevating (t=-4.409, P<0.05); the proportion of experts with strong error correction ability (error correction ratio≥80%) was elevated from 32.2% to 50.9%, a difference of statistical significance (P<0.05).@*Conclusions@#Archived medical record management can encourage medical quality management. The quality of medical records, especially the connotation quality of medical records has been improved. The ability of some quality control experts was also enhanced. The quality management system at hospital and department levels has made major progress.