Analysis on singe-item rejection projects of 4858 medical records

Abstract

Objective To carry out the analysis on the single-item rejection projects of grade B and grade C medical records,uncovering the reason for major defects of the quality of medical records,accordingly offering countermeasures and suggestions.Methods We inspected 4858 cases of electronic in-hospital medical record randomly,dividing them into non-surgical department and surgical department.Then checked the differences between two cases on the ratio of the non-A grade medical records and the occurrence rate of defects using x2 method.Results In surgical department,the ratio of grade B medical records was 2.58％,the ratio of grade C medical records was 0.99％,higher than those of grade B medical records and grade C medical records of non-surgical department which were 1.37％ and 0.04％ respectively.The most major defect of grade B projects in surgical department or non-surgical department was the lack of various kinds of letter of consent or valid signatures (the occurrence rate was 1.31％ and 0.64％ respectively).The above-mentioned differences were obvious.Grade C projects of surgical department were mainly focused on the lack of anesthesia notes (0.79％),next on the lack of surgery records (0.16％).Conclusion Only by fully paying attention to the quality of the medical record from different levels of medical staff and administrative staff of hospitals,can the major defects be reduced or prevented,the quality of the medical record is improved and the medical safety be ensured. Key words: Single-item rejection project; Quality of medical record; Grade B medical record; Grade C medical record