Reasons and Countermeasures for Delayed Filing of Medical Records Abstract Objective The timely filing of medical records after discharge directly affects the work of statistics, sorting and filing. Methods The causes of delayed filing of medical records were analyzed, and the common problems affecting timely recovery of medical records were discussed. Results Hospital leaders at all levels should pay attention to it, grasp the important link of medical record filing, and realize the programmed management of medical record filing.

Keywords: reasons and countermeasures for delayed filing of discharged medical records

The delay in filing medical records will directly affect the follow-up process of medical record management and the reuse of medical record information resources. For a long time, the phenomenon of delayed filing of medical records still exists due to the management mode and medical record process. Only by collecting medical records in time can we ensure the full expression of the value of medical records, complete statistical work on schedule, provide information, better adapt to legal needs, prevent medical disputes and serve patients and society.

Cause analysis of 1

The supervision of 1. 1 is insufficient.

It is clearly recorded in the routine operation of medical care technology that the discharge medical records are filed for three days and the death medical records are filed for seven days. According to the above regulations, our hospital has formulated relevant regulations and reward and punishment methods suitable for our specific situation. Medical record managers are afraid of "face" offending people in the process of implementation, and departments that delay filing medical records often cannot strictly implement the management system, and the reward and punishment system has become a dead letter.

1.2 Doctors pay insufficient attention to medical records.

Doctors end the clinic, ignore the writing of medical records, the writing of medical records is not timely, and all kinds of medical records are not completed within the specified time; Medical records are everywhere and can't be found at the moment; The medical records are filed in the medical record room. After examination by the quality control personnel in the medical record room, it was found that there were mistakes or omissions in the first page of the medical record, and there was no course record due to the medical record, so the treatment was incomplete. Inform the doctor that he did not go to the medical record room in time to make amendments or supplements, which delayed the filing time of medical records.

1.3 department director's approval is not timely.

Some department directors don't have a strong sense of management, don't know the number of discharged patients, often go out for study, meetings and consultations, and can't sign the discharge medical records in time. Some department directors even think that treatment and surgery cannot be delayed, and it is no problem to file medical records a few days later. They didn't take medical records as their daily work, but rechecked them when they accumulated a lot of medical records, which affected the timely submission of discharged medical records.

1.4 Some death medical records were not discussed on time.

After the discussion, the doctor did not arrange it in time, so the filing time was postponed.

1.5 The nurse failed to sort out the discharge medical records in time.

Nurses have to calculate the hospitalization expenses one by one when dealing with many discharged patients, especially when sorting out the discharge medical records and death medical records of critically ill patients, there are dozens or even hundreds of nursing records and inspection reports, which are too late to sort out and submit, resulting in delays in filing medical records. 1.6 The defect of the electronic medical record system leads to the delay of medical record filing.

Due to system failure, sudden power failure and other reasons, the information of personal medical records in the computer is lost, unable to be recovered or filed too late, so doctors have to rewrite the medical records and delay the filing time.

2 countermeasures

2. 1 Strictly implement the medical record recovery system.

For those who delay the filing of medical records without special reasons, corresponding economic penalties should be given. Punishment is not an end, but a means to restrain the relevant responsible personnel. Only by truly recognizing the importance of medical records can medical records return in time. Finish daily work such as statistics in time.

2.2 hospitals to increase medical record quality management.

Medical record quality is an important part of medical quality. Medical department and quality control team should not only monitor the quality of final medical records, but also pay attention to the quality control of link medical records. Regularly check the writing quality and completion of medical records in the next department. Hold a medical quality evaluation meeting every month, announce the inspection results, and link them with the evaluation of medical staff.

2.3 establish and improve the department management system

By the director of the department, the head nurse * * * to cooperate with the check, so that each ward will be responsible for the filing management of hospital medical records, with a special discharge register, and establish strict handover registration procedures with the discharge office and medical record room.

2.4 Medical record managers should improve their own quality and professional level.

The workflow of medical records has been improved and optimized. The staff of the medical record statistics room go to the inpatient office every day to collect the medical records discharged the day before. Under strict collection and supervision, the 24-hour recovery rate has been greatly improved.

3 discussion

The delay in filing medical records ranges from a few days to more than ten days or even longer, which is a "bottleneck" in medical record management. Delayed filing of medical records not only directly affects the follow-up work such as cataloging, sorting, auditing, signing, binding and shelving of medical records, but also hinders statistical work, and medical information cannot be used in time and effectively, even leading to adverse consequences such as disputes between doctors and patients. Therefore, hospital leaders should attach importance to medical record management, establish and improve medical record filing mechanism, and implement effective supervision and management. Actively adopt reasonable suggestions and opinions put forward by medical record managers, and pay enough attention to the phenomenon that medical records cannot be filed in time. Secondly, medical record managers should strive to improve their own quality and professional ability, strictly implement the reward and punishment system, change passivity into initiative, pay serious and responsible attention to medical record filing, actively cooperate with this work, recycle it in time and file it within a time limit. Avoid the adverse consequences caused by delayed filing of medical records. ;