2014•Chinese Medical Record English EditionRequires access
Effect of Step-by-step Quality Control on the Quality of Electronic Medical Records
Wei He, Yankai Ma, Yunna Ma, Xian Li
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Abstract
Objective. To explore the effect of step-by-step quality control on the quality of electronic medical records. Method. To randomly extract 6,200 final medical records generated from July 2012 to December 2012 and 6,200 electronic medical records generated from January 2013 to June 2013, after step-by-step quality control is implemented in the network, to track the quality of the final medical records after step-by-step quality control. The final medical records are checked and evaluated according to the Basic Criterion of Documentation of the Medical Record issued by the Ministry of Health; the quality of medical records, defects in real-time, and writing defects are analyzed statistically. Results. Compared with the medical records generated from July 2012 to December 2012, the rate of grade A medical records generated from January 2013 to June 2013 is increased by 4.46% (P < 0.01), the rate of grade B medical records is decreased by 4.43% (P < 0.01), and the rate of grade C medical records is decreased from 0.03% to 0%; the defect rate relating to real-time is decreased significantly, and the writing defects are fewer than before. Conclusion. The step-by-step quality control of electronic medical records can reduce the defects in medical records and effectively improve the quality of the final medical records.