Quality Management of Homepages of Medical Records

Abstract

AbstractObjectives. To quantitatively assess the quality of homepages of medical records, for further improvement. Methods. Twenty quality control points were set up according to “Some Regulations in Instructions for Filling in Homepages of the Medical Records”, issued by the National Health and Family Planning Commission of the PRC in 2012; and a Homepage Inspection Marking Table was developed and used for the quality control of the homepages of 167 medical records with the same date of discharge. Results. The pass rate for the filling-in of the homepages of medical records was 95.2%; the rate of omission of the patient's basic information was the highest, accounting for 29.9%; the rate of incorrect diagnostic conformances was up to 12.6%; and the rate of omission of the pathology number, the reason for damage and poisoning, and the anaphylactic drug, accounted for 10.8%. Conclusions. The quality of the homepages of the medical records can be improved through strengthening the learning assessment and the...