{"title":"2024 年海阳综合医院护士记录住院病人病历的情况","authors":"Thi Lien Ha, Duy Hung Dao","doi":"10.54436/jns.2024.02.783","DOIUrl":null,"url":null,"abstract":"Objectives: To describe the current status of medical records by nurses in select clinical departments at Hai Duong General Hospital in 2024.\nMethods: A cross-sectional study was conducted among 402 medical records from 4 internal medicine departments and 4 surgical departments at Hai Duong General Hospital in April 2022.\nResults: The percentage of satisfactory medical records was found to be 84.1%.\nConclusion: The current status of medical records in certain clinical departments at Hai Duong General Hospital was quite good. Further research and improvements in documentation forms and practices are necessary to enhance the quality of medical records.","PeriodicalId":504442,"journal":{"name":"Tạp chí Khoa học Điều dưỡng","volume":null,"pages":null},"PeriodicalIF":0.0000,"publicationDate":"2024-03-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Status of recording inpatient medical records by nurses at Hai Duong General Hospital in 2024\",\"authors\":\"Thi Lien Ha, Duy Hung Dao\",\"doi\":\"10.54436/jns.2024.02.783\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"Objectives: To describe the current status of medical records by nurses in select clinical departments at Hai Duong General Hospital in 2024.\\nMethods: A cross-sectional study was conducted among 402 medical records from 4 internal medicine departments and 4 surgical departments at Hai Duong General Hospital in April 2022.\\nResults: The percentage of satisfactory medical records was found to be 84.1%.\\nConclusion: The current status of medical records in certain clinical departments at Hai Duong General Hospital was quite good. Further research and improvements in documentation forms and practices are necessary to enhance the quality of medical records.\",\"PeriodicalId\":504442,\"journal\":{\"name\":\"Tạp chí Khoa học Điều dưỡng\",\"volume\":null,\"pages\":null},\"PeriodicalIF\":0.0000,\"publicationDate\":\"2024-03-08\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Tạp chí Khoa học Điều dưỡng\",\"FirstCategoryId\":\"1085\",\"ListUrlMain\":\"https://doi.org/10.54436/jns.2024.02.783\",\"RegionNum\":0,\"RegionCategory\":null,\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"\",\"JCRName\":\"\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Tạp chí Khoa học Điều dưỡng","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.54436/jns.2024.02.783","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
Status of recording inpatient medical records by nurses at Hai Duong General Hospital in 2024
Objectives: To describe the current status of medical records by nurses in select clinical departments at Hai Duong General Hospital in 2024.
Methods: A cross-sectional study was conducted among 402 medical records from 4 internal medicine departments and 4 surgical departments at Hai Duong General Hospital in April 2022.
Results: The percentage of satisfactory medical records was found to be 84.1%.
Conclusion: The current status of medical records in certain clinical departments at Hai Duong General Hospital was quite good. Further research and improvements in documentation forms and practices are necessary to enhance the quality of medical records.
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