Continuous improvement measures for medical record writing quality control management

1. Overall quality control objectives for medical record writing

Strictly implement medical record quality control standards and file Class A medical records The rate is over 90%, the Grade B rate is controlled within 10%, the Grade C medical records are controlled at zero, and the 9 types of medical records that are single-item rejected as Grade C are controlled at zero.

2. Quality control and continuous improvement of medical record writing

(1) The main problems existing in the current quality control of medical records:

1. Pay attention to form and ignore connotation, resulting in the implementation of the core system becoming a mere formality

2. Hospital management is not strict and relevant rules and regulations are not strictly implemented.

3. The department quality control team is not serious and responsible, and the quality control intensity is not enough.

4. Medical staff lack knowledge, mainly lack of knowledge of traditional Chinese medicine.

5. The medical record quality monitoring process is not standardized.

(2) Main problems existing in the writing of medical records last year

1. The main diagnostic errors are inconsistent with the condition.

2. Admission record: The doctor who wrote it is not qualified enough.

3. Failure to sign long-term medical advice.

4. The disease course record exceeds the time limit.

5. The superior doctor’s ward round records are too simplified and have the same content. There is no efficacy analysis, no specific treatment measures, and no guidance for treatment.

6. Some doctors’ medical records have illegible handwriting and untidy pages.

7. The dialectical classification of traditional Chinese medicine is the same.

8. The differential diagnosis of TCM medical records is inadequate, the dialectics are too simple, and the content is not comprehensive enough.

(3) Analysis of the causes of the above problems

1. Doctors lack understanding, mainly lack of knowledge of traditional Chinese medicine.

2. Some doctors do not have a strong sense of responsibility and are careless in their work

3. Hospital leaders do not pay much attention to it, and department leaders do not strictly control it

4. Quality The control personnel were not serious and responsible, and quality control was not strong enough.

(4) Formulate continuous improvement measures and implementation plans

1. To strengthen professional learning, the medical department should increase training efforts and improve training methods.

2. Hospital leaders and department leaders should raise awareness, strictly manage, and formulate supporting reward and punishment measures.

3.

2. Increase training intensity, formulate corresponding and feasible training plans, and improve training methods.

3. Improve the hospital’s three-level medical record quality control management system.

4. Standardization of examinations: unified and standardized forms of medical records to reduce system errors, train examiners, make examination standards unified, and examination results quantified and comparable;

5. Inspection system Standardization: Assessment methods and methods form a standardized system, including result feedback, reward and punishment measures, continuous improvement measures, etc.

6. Use the quality of medical record writing as an indicator to evaluate the quality of department and individual medical work, and develop a strong and feasible reward and punishment mechanism.

Medical Record Room of Langao County Hospital of Traditional Chinese Medicine

March 6, 2013