In the new standard (2022 edition), the quality management of medical records is included in the quality control as one of the 19 key specialties, and in addition to the resource allocation indicators, there are 23 quality indicators of medical record writing.
These indicators are undoubtedly very important, so let's take a look at what they mean:
There is no doubt that the above 23 indicators are very important for evaluating the quality of a medical record. The question is, if all the information cannot be used, mainly relying on manual work, how much manpower is needed to collect all the data of these indicators? The approximate calculation is as follows:
Taking the general municipal tertiary hospitals as a calculation, 100,000 medical records a year, according to the above indicators to make a checklist to collect data, each medical record needs at least 30 minutes. A quality controller can see up to 4,000 medical records a year according to 250 working days × 250 hours = 2,000 hours = 2,000 hours a year; 100,000 medical records require at least 25 quality controllers to check them for 8 hours every working day throughout the year. I believe that it is almost impossible for a tertiary hospital in the country to have so many experts to check medical records.
In reality, the quality control of terminal medical records in hospitals is generally carried out by retired experts, or a small number of backbone doctors are temporarily dispatched at the end of each month, and it is difficult to ensure that three people can work for 8 hours a day. Therefore, it is impossible to get things done. The above does not include the manpower of coders.
Therefore, if the top three review requires the hospital to carry out quality control of the whole sample of the medical record, it is extremely difficult to achieve, like data for the sake of data, which is meaningless.
Unless, the quality control of medical records is completely AI-based and fully intelligent, then there is no problem. But this seems far away. Or, the first-level quality control is adopted, and the above 23 indicators are controlled when the medical records are discharged. But this is the doctor's own evaluation, and it is impossible to be completely objective and truthful.
It is more reasonable to do quality control by sampling. According to a national medical record quality control expert, a 2% sampling is sufficient. 2,000-10,000 quality control of 100,000 medical records a year, most hospitals can still do it with their efforts, and it is also in line with the spirit of quality control. Full sample or sampling, that's really the question.
From the perspective of time, the quality control of medical records is divided into link quality control and terminal quality control. By the time the medical record is formed, the medicine has been eaten/injected into the body, and the person has been discharged/passed away, and the quality control at this time is nothing more than pruning the branches and leaves, not to talk about the fundamentals. Therefore, the focus of medical record quality control must be link quality control. Correcting defects when they are not or are in the process of forming.
From the perspective of nature, the quality control of medical records is divided into formal quality control and connotative quality control.
- The standard of medical record writing format is the external quality - format quality control;
- The connotative quality of medical record writing is the intrinsic quality (reflecting the level of medical technology, diagnosis and treatment) - connotative quality control.
Connotative quality control is the foundation of medical record quality control, and the highest level expected to be achieved by connotative quality control is: clear diagnosis and reasonable diagnosis and treatment measures.
It is easy to find that the medical records are missing, blank, typos, and unreasonable copying of medical records. It is difficult and valuable to correct the diagnostic errors and diagnosis and treatment errors of clinicians through medical records. Only paying attention to the form quality control and ignoring the connotation quality control is undoubtedly picking up the sesame seeds and losing the watermelon.
Finally, the main points of writing the chief complaint, present medical history and daily course of the medical record are attached for reference.
1. You can think about it when writing medical records
Who is the medical object? Who is prescribing the doctor's order? Who is carrying out the doctor's order? What is the medical treatment for the disease ? Why is this the medical treatment necessary? Where is the medical procedure performed? How does the medical activity work?
2. Writing of admission records
1. General items:
Complaints: main symptoms, signs, duration
- The complaint is about 20 words
- Presenting symptoms are written in the order in which they occur
- Symptomatic complaints, diseases for which special treatment has been clearly diagnosed, and asymptomatic examinations
- No more than 3 presenting symptoms
2. History of present illness:
Focusing on the chief complaint, the occurrence, evolution, diagnosis and treatment of the disease. Write in chronological order.
- Onset: time, place, onset, prodromal symptoms, possible causes or triggers
- Characteristics of main symptoms: in order of occurrence: location, nature, duration, degree, alleviating or aggravating factors of the main symptoms◦ Development and change of the main symptoms
- Concomitant symptoms: The relationship between concomitant symptoms and the main symptoms◦ Diagnosis and treatment history, results: Examination and treatment, results
- General conditions such as sleep, diet, mental state, sleep, appetite, urine and bowel movements, weight, physical strength
- Positive or negative data related to the differential diagnosis
The history of the disease should also be recorded.
3. Record of daily course of illness
• Physiological and psychological state and changes in the patient's condition:
- Conscious symptoms, mood, psychological state, diet, sleep, urine and bowel movements
- New signs and symptoms should be analyzed to cause the changes
- Whether there are complications and possible causes for their occurrence
- Revised diagnosis and new diagnosis and basis for diagnosis
• Important ancillary findings and clinical significance
• Physician's rounds
• Diagnosis and treatment measures taken and their effects
• Important information to inform patients and their close relatives
Source: Medical Power Medical Management Center (Reprinted for sharing only, the copyright belongs to the original author.) If there is an error or infringement of the source, please contact us, we will correct and delete it in time, thank you! ）
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