Chất lượng ghi hồ sơ bệnh án sản khoa tại một đơn vị trong giai đoạn chuyển đổi sang hồ sơ bệnh án điện tử

Abstract

To assess the quality of inpatient obstetrics medical record documentation and analyze the factors affecting it at the University Medical Center Ho Chi Minh City - Branch 2. A cross-sectional study was conducted to evaluate 195 inpatient obstetrics medical records from June 2023 to August 2023, in-depth interviews were carried out with 6 healthcare staff members at the hospital. The overall quality of recording general medical records is 21.5%; in the administrative information section, it is 80.5%; in the medical record section, it is 80.5%; the content of medical orders and their implementation is 52.8%, and the overall summary of medical records is 67.2%. The rate of complete documentation varies for medical records that use health insurance and service medical records. Factors influencing the quality of medical record keeping include the age and gender of healthcare staff, workload, multiparous women with comorbidities, training processes, and monitoring of medical record keeping. The quality of medical record-keeping is low, with the lowest being in the content of medical orders and their implementation. Training and training programs need to be organized for new healthcare staff, and regular monitoring checks for paper medical record keeping should be implemented. At the same time, the rapid development of electronic medical records should be undertaken to reduce the time spent on documentation and integrate the process of implementing medical orders for patients.