Abstract
Objective. To investigate the content and method of quality control for clinical pathway (CP) medical records. Methods. The items of quality control for medical records were established according to standardized CP of hospitalization process and treatment chart for patients having acute ST-elevation myocardial infarction. Totally 121 cases of acute ST-elevation myocardial infarction were investigated for medical records quality based on clinical pathway. Results. Out of the 121 medical records of acute ST-elevation myocardial infarction, the length of hospitalization time is the most unconformable item in CP standard with a defect rate of 14.1%, while the admission diagnosis, diagnostic evidence, inspection items, operation time, the discharge evaluation, and variation factors possess a defect rate between 4.1% and 12.4%. Conclusion. The quality control of medical record is closely related to the standardization of CP implementation. It will be helpful in carrying out CP through setting up a standardized CP medical record quality control system and CP medical record quality control measures for implementing focus on CP management.
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