Pub Date : 2014-12-15DOI: 10.3109/23256176.2014.992175
Meixiao Chen, Zhenhui Lu
AbstractObjectives. To probe the effects of the standards of evaluation of medical record quality management applied in a second class grade A general hospital. Methods. We analyzed the quality status of two hundred patient records, asked for reasons, carried out PDCA circulation management, and compared the quality evaluation scores, rates of class A medical records, and the screening rates of hospitalization records, before and after PDCA circulation management. Results. The results demonstrated before PDCA circulation management were obviously better than those after PDCA circulation management, and the difference was statistically significant (P < 0.05). Conclusions. It is obvious that medical record quality can be improved significantly through PDCA management in combination with the evaluation standards of a second class grade A general hospital.
{"title":"Effects of PDCA Applied to Medical Record Quality Management","authors":"Meixiao Chen, Zhenhui Lu","doi":"10.3109/23256176.2014.992175","DOIUrl":"https://doi.org/10.3109/23256176.2014.992175","url":null,"abstract":"AbstractObjectives. To probe the effects of the standards of evaluation of medical record quality management applied in a second class grade A general hospital. Methods. We analyzed the quality status of two hundred patient records, asked for reasons, carried out PDCA circulation management, and compared the quality evaluation scores, rates of class A medical records, and the screening rates of hospitalization records, before and after PDCA circulation management. Results. The results demonstrated before PDCA circulation management were obviously better than those after PDCA circulation management, and the difference was statistically significant (P < 0.05). Conclusions. It is obvious that medical record quality can be improved significantly through PDCA management in combination with the evaluation standards of a second class grade A general hospital.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"19 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125305387","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-12-15DOI: 10.3109/23256176.2014.992164
J. Ni, Xian-rong Xu, Haifeng Gu, R. Chen
AbstractThe standardization of diagnosis and coding of burn injuries is an effective way to improve the quality of medical records of burn injuries. Based on the characteristics of the burn injuries, we suggest that the diagnosis of burn injuries should include the diagnosis of burn, diagnosis of complications, and diagnosis of coexisting conditions; the methods of writing the diagnosis of burn injury, choice of the main diagnosis, and ICD-10 coding are described in detail in this paper.
{"title":"Discussion on the Diagnosis of Burn Injuries and ICD-10 Coding","authors":"J. Ni, Xian-rong Xu, Haifeng Gu, R. Chen","doi":"10.3109/23256176.2014.992164","DOIUrl":"https://doi.org/10.3109/23256176.2014.992164","url":null,"abstract":"AbstractThe standardization of diagnosis and coding of burn injuries is an effective way to improve the quality of medical records of burn injuries. Based on the characteristics of the burn injuries, we suggest that the diagnosis of burn injuries should include the diagnosis of burn, diagnosis of complications, and diagnosis of coexisting conditions; the methods of writing the diagnosis of burn injury, choice of the main diagnosis, and ICD-10 coding are described in detail in this paper.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"68 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130008243","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-10-13DOI: 10.3109/23256176.2014.970755
Y. Zhang
AbstractIn order to meet the needs of new medical reform and high-quality nursing service, meeting the treatment needs of patients and improving the patient satisfaction are essential. The hospital took some measures, such as optimizing outpatient service procedure, diagnosis and treatment at different periods, appointing registration through different ways, and establishment and improvement of outpatient doctor workstation and electronic triage nurse calling system. Based on the increase in number of outpatients, the satisfaction of the outpatients is promoted. The results indicate that with the increase in number of outpatients, the demand for the service in outpatient department becomes higher. The hospital can meet the needs of the patients only by constant improvement and innovation of hospital service and reflection of the people-oriented concept.
{"title":"Practice and Discussion of Carrying Out High-Quality Service in Out-Patient Department","authors":"Y. Zhang","doi":"10.3109/23256176.2014.970755","DOIUrl":"https://doi.org/10.3109/23256176.2014.970755","url":null,"abstract":"AbstractIn order to meet the needs of new medical reform and high-quality nursing service, meeting the treatment needs of patients and improving the patient satisfaction are essential. The hospital took some measures, such as optimizing outpatient service procedure, diagnosis and treatment at different periods, appointing registration through different ways, and establishment and improvement of outpatient doctor workstation and electronic triage nurse calling system. Based on the increase in number of outpatients, the satisfaction of the outpatients is promoted. The results indicate that with the increase in number of outpatients, the demand for the service in outpatient department becomes higher. The hospital can meet the needs of the patients only by constant improvement and innovation of hospital service and reflection of the people-oriented concept.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"6 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115573230","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-10-13DOI: 10.3109/23256176.2014.970008
Liangyu Wei, Pengchen Sun, X. Luan, Chao Li
AbstractThe patients’ right to informed consent has been paid more and more attention by a wide cross- section of society, which also means higher requirements for doctors in fulfilling the obligation of instructions. The experience of mediating medical malpractice prompts doctors to notice that fulfilling the obligation of instructions effectively should be a dynamic process that has always run through the medical act. It is especially easy to overlook and forget to inform the patient or family members about the intraoperative accident. By analyzing a relevant typical medical malpractice case, this paper discusses the issues related to fulfilling the doctors’ obligation of instructions in surgery, and reflects on different infringements of patients’ right to informed consent.
{"title":"An Analysis of a Medical Malpractice Case Caused by Ignoring the Obligation of Instruction during Surgery","authors":"Liangyu Wei, Pengchen Sun, X. Luan, Chao Li","doi":"10.3109/23256176.2014.970008","DOIUrl":"https://doi.org/10.3109/23256176.2014.970008","url":null,"abstract":"AbstractThe patients’ right to informed consent has been paid more and more attention by a wide cross- section of society, which also means higher requirements for doctors in fulfilling the obligation of instructions. The experience of mediating medical malpractice prompts doctors to notice that fulfilling the obligation of instructions effectively should be a dynamic process that has always run through the medical act. It is especially easy to overlook and forget to inform the patient or family members about the intraoperative accident. By analyzing a relevant typical medical malpractice case, this paper discusses the issues related to fulfilling the doctors’ obligation of instructions in surgery, and reflects on different infringements of patients’ right to informed consent.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"17 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121918425","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-10-13DOI: 10.3109/23256176.2014.970756
S. Teng
AbstractObjective. To investigate measures to reduce medical costs. Methods. By studying the degree of structural change and indicators of the speed of growth, the status of changes in the expense composition over the past six years is analyzed. Result. The change of expense composition is reasonable; other fees and inspection fees are responsible for the major changes in the expense composition, and the cumulative contribution of the two fees is 42.50%; the structural change in the care fee is small, and the increase is only 4.10%; it indicates that the value of nursing services should be increased along with the increase in the value of medical service provided by the doctors; the drug costs, medical fees and surgical fees are the three major components to be decreased in the composition of hospitalization expense, and the cumulative contribution of the three parts is 45.88%; it indicates that the fee structure is optimized in our hospital, and the management awareness is also strengthened. Conclusion. ...
{"title":"Application of Structural Change Degree in the Analysis of Changes in the Composition of Hospitalization Expenses","authors":"S. Teng","doi":"10.3109/23256176.2014.970756","DOIUrl":"https://doi.org/10.3109/23256176.2014.970756","url":null,"abstract":"AbstractObjective. To investigate measures to reduce medical costs. Methods. By studying the degree of structural change and indicators of the speed of growth, the status of changes in the expense composition over the past six years is analyzed. Result. The change of expense composition is reasonable; other fees and inspection fees are responsible for the major changes in the expense composition, and the cumulative contribution of the two fees is 42.50%; the structural change in the care fee is small, and the increase is only 4.10%; it indicates that the value of nursing services should be increased along with the increase in the value of medical service provided by the doctors; the drug costs, medical fees and surgical fees are the three major components to be decreased in the composition of hospitalization expense, and the cumulative contribution of the three parts is 45.88%; it indicates that the fee structure is optimized in our hospital, and the management awareness is also strengthened. Conclusion. ...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115687373","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-10-13DOI: 10.3109/23256176.2014.970011
Jie Min, Dezeng Zhu
AbstractObjective. To design and realize an integrated diabetes management system using traditional Chinese medicine (TCM). Method. With the inspection records, expert consultation, myriad of operations, the reference to similar software, and by referring to the standard data, we developed the overall functional goal, selected reasonable system architecture and the design function of system hierarchy, and designed the function of each module in the system. Result. The system was developed based on J2EE architecture, using a three-layered structure of browser/server (B/S), and used to determine the acquisition and range of seven kinds of data. Conclusion. The system provided a platform for management of diabetic patients in the community, with the characteristics of TCM. It will implement structured data acquisition and storage. In addition, it is a practical tool for clinical decision making and management of cases related to diabetes.
{"title":"Design and Implementation of Traditional Chinese Medicine for an Integrated Diabetes Management System","authors":"Jie Min, Dezeng Zhu","doi":"10.3109/23256176.2014.970011","DOIUrl":"https://doi.org/10.3109/23256176.2014.970011","url":null,"abstract":"AbstractObjective. To design and realize an integrated diabetes management system using traditional Chinese medicine (TCM). Method. With the inspection records, expert consultation, myriad of operations, the reference to similar software, and by referring to the standard data, we developed the overall functional goal, selected reasonable system architecture and the design function of system hierarchy, and designed the function of each module in the system. Result. The system was developed based on J2EE architecture, using a three-layered structure of browser/server (B/S), and used to determine the acquisition and range of seven kinds of data. Conclusion. The system provided a platform for management of diabetic patients in the community, with the characteristics of TCM. It will implement structured data acquisition and storage. In addition, it is a practical tool for clinical decision making and management of cases related to diabetes.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"9 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126615060","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-10-13DOI: 10.3109/23256176.2014.969476
Chunguo Xing, Dongni Sun, Lingyong Liu, Q. Chen, Qianwen Liu, Ying Shi, N. Wang
AbstractObjective. To investigate the staff working in the medical record management offices of a hospital and the students of related majors in a province, to know the conditions of demand for medical record personnel by the medical institutions of the province. Method. Nineteen hospitals of a province were investigated with scale analysis and interviews. There were 15 tertiary hospitals, 3 secondary hospitals, and 1 community health service center participating in the investigation. Nine hospitals of a neighboring province were also investigated and rated for reference. Meanwhile, the interns and graduates in charge of medical records were investigated with regard to their working conditions. Result. The hospitals studied have basically implemented the use of computers, and the ratio of the medical record management staff is increased every year. Many hospitals, however, are badly in need of medical record management personnel, due to the lack of availability of talented individuals, for example, those ...
{"title":"Investigation of Demand and Analysis of Medical Record Management Personnel in Medical Institutions of a Province","authors":"Chunguo Xing, Dongni Sun, Lingyong Liu, Q. Chen, Qianwen Liu, Ying Shi, N. Wang","doi":"10.3109/23256176.2014.969476","DOIUrl":"https://doi.org/10.3109/23256176.2014.969476","url":null,"abstract":"AbstractObjective. To investigate the staff working in the medical record management offices of a hospital and the students of related majors in a province, to know the conditions of demand for medical record personnel by the medical institutions of the province. Method. Nineteen hospitals of a province were investigated with scale analysis and interviews. There were 15 tertiary hospitals, 3 secondary hospitals, and 1 community health service center participating in the investigation. Nine hospitals of a neighboring province were also investigated and rated for reference. Meanwhile, the interns and graduates in charge of medical records were investigated with regard to their working conditions. Result. The hospitals studied have basically implemented the use of computers, and the ratio of the medical record management staff is increased every year. Many hospitals, however, are badly in need of medical record management personnel, due to the lack of availability of talented individuals, for example, those ...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130996982","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-10-13DOI: 10.3109/23256176.2014.970000
Jiali Liu, Zixing Chen
AbstractObjective. To discuss the factors influencing the standard test indexes of the average length of stay of a patient before elective surgery. Methods. The reasons were identified by analyzing cases of extra-long duration of stay before elective surgery in the first half of 2013 of a 3A hospital. Results. The reasons were physician enrollment, more than two elective operations in one instance of hospitalization, elective surgery, and failure in the treatment of the main disease; before intervention, the preoperative average length of stay was 3.53 days, and was reduced to 2.7 days after intervention. Conclusion. A formulated library of names of elective surgery, the removal of choices irrelevant to checking, and the creation of computerized audit programs, automatic screening of index time calculation, and so on, helped to check and continuously improve the levels of medical management.
{"title":"A Discussion on the Reasons for Excessive Average Preoperative Hospitalization Days","authors":"Jiali Liu, Zixing Chen","doi":"10.3109/23256176.2014.970000","DOIUrl":"https://doi.org/10.3109/23256176.2014.970000","url":null,"abstract":"AbstractObjective. To discuss the factors influencing the standard test indexes of the average length of stay of a patient before elective surgery. Methods. The reasons were identified by analyzing cases of extra-long duration of stay before elective surgery in the first half of 2013 of a 3A hospital. Results. The reasons were physician enrollment, more than two elective operations in one instance of hospitalization, elective surgery, and failure in the treatment of the main disease; before intervention, the preoperative average length of stay was 3.53 days, and was reduced to 2.7 days after intervention. Conclusion. A formulated library of names of elective surgery, the removal of choices irrelevant to checking, and the creation of computerized audit programs, automatic screening of index time calculation, and so on, helped to check and continuously improve the levels of medical management.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"48 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128206746","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-10-13DOI: 10.3109/23256176.2014.969481
Jun Song, Yubang Chen, Junchao Zhao
AbstractDiscussion about the Disadvantages of Coding Patterns in the ICD Dictionary Library. There are two kinds of common coding patterns in the ICD dictionary library: one is a regular pattern of coding with the ICD coding reference book, based on a three-step coding (confirmation of pivotal words, search of codes in an index, collation of the codes []) method, the other is to mechanically apply a name similar to the name of the operation written by the doctor. The present article reviews and analyzes the ICD coding of 563 cardiovascular intervention surgeries, dissects the cause of deviations in ICD coding, and aims at applying the regular coding pattern instead of the elementary coding pattern of mechanically applying a similar name simply depending on a computer, based on the cardiovascular intervention surgeries, so as to improve the accuracy of the ICD coding.
{"title":"Discussion about Phasing Out the Disadvantages of Coding Patterns in the ICD Dictionary Library","authors":"Jun Song, Yubang Chen, Junchao Zhao","doi":"10.3109/23256176.2014.969481","DOIUrl":"https://doi.org/10.3109/23256176.2014.969481","url":null,"abstract":"AbstractDiscussion about the Disadvantages of Coding Patterns in the ICD Dictionary Library. There are two kinds of common coding patterns in the ICD dictionary library: one is a regular pattern of coding with the ICD coding reference book, based on a three-step coding (confirmation of pivotal words, search of codes in an index, collation of the codes []) method, the other is to mechanically apply a name similar to the name of the operation written by the doctor. The present article reviews and analyzes the ICD coding of 563 cardiovascular intervention surgeries, dissects the cause of deviations in ICD coding, and aims at applying the regular coding pattern instead of the elementary coding pattern of mechanically applying a similar name simply depending on a computer, based on the cardiovascular intervention surgeries, so as to improve the accuracy of the ICD coding.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"400 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"120892122","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-10-13DOI: 10.3109/23256176.2014.970003
Xiaoqing Zhou, Xiaomei Fang, Feng Xiao
AbstractAlong with development of evidence-based medicine and the high frequency of examination of medical records, obtaining the required medical record easily and rapidly is an important link in the task of medical record management. Three kinds of medical record tracers (barcode, two-dimensional code, and RFID electronic label) are introduced into medical record management; the authors comparatively investigate the three key technologies used in medical record tracing, from the perspectives of ability to read information, capacity for storage of information, and current status of technological development, and summarize their features. The technology of the RFID electronic label is found to have significant advantages in the three aspects mentioned above. The authors investigate the superiority of integrating the technology of RFID electronic labeling with that of barcoding or two-dimensional coding in the management of medical records, to compensate for the shortcomings of each technology when used al...
{"title":"Comparative Research of Key Technologies in Medical Record Tracing","authors":"Xiaoqing Zhou, Xiaomei Fang, Feng Xiao","doi":"10.3109/23256176.2014.970003","DOIUrl":"https://doi.org/10.3109/23256176.2014.970003","url":null,"abstract":"AbstractAlong with development of evidence-based medicine and the high frequency of examination of medical records, obtaining the required medical record easily and rapidly is an important link in the task of medical record management. Three kinds of medical record tracers (barcode, two-dimensional code, and RFID electronic label) are introduced into medical record management; the authors comparatively investigate the three key technologies used in medical record tracing, from the perspectives of ability to read information, capacity for storage of information, and current status of technological development, and summarize their features. The technology of the RFID electronic label is found to have significant advantages in the three aspects mentioned above. The authors investigate the superiority of integrating the technology of RFID electronic labeling with that of barcoding or two-dimensional coding in the management of medical records, to compensate for the shortcomings of each technology when used al...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"27 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114646423","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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