Continuous Improvement of the Electronic Medical Record Quality Control System

Abstract

Objective. To analyze the defects in the quality control of the currently active medical records and discuss continuous improvement measures for improving the quality of the active medical records, so as to promote the comprehensive improvement of medical quality. Method. Extracting electronic medical records of the surgical department and the electronic medical records of the department of internal medicine, respectively, in 2012 and 2013, evaluating the situation of defective medical records, analyzing by employing the SPSS15.0 statistical software package, processing and counting with the t-test. Results. After the quality control work process is completed and the quality control informatization management is enhanced, the percentage of defective medical records of the departments of surgery and internal medicine are obviously reduced after the improvement, showing a significant difference and indicating a statistical significance (P is less than 0.01); the percentage mean after the improvement is remarkably lower than that before the improvement, showing a significant difference and indicating a statistical significance (P is less than 0.01). The average score of the medical record quality control in 2013, after the improvement, is significantly higher than that of the medical record quality control in 2012 of the same term. Therefore, the improvement of A-grade medical record rate is promoted and the number of medical disputes is decreased significantly. Conclusion. Completing the quality control system and informatization management of the electronic medical records and enhancing the continuous improvement to continuously perfect the quality of active medical records are steps that not only effectively reduce the medical risk, but also play an important part in fully enhancing the inherent medical quality.