The Influence of Human Factors on Medical Record First Page Filling, on HQMS Data

Abstract

Objective. To analyze the influence of the preliminary rectification of medical record first page filling on the HQMS data, in order to propose corresponding management measures to improve the extraction quality of HQMS data. Methods. Data about the first page of the discharge medical records were collected and a statistical analysis was carried out before rectification, between September and November in 2013, and after rectification, between December in 2013 and January and February in 2014. Results. After rectification, some data of HQMS are significantly improved, such as the no-filling rate of the grade of surgical anesthesia, which fell from 12.80% to 9.61% (χ2 = 4.84, P < 0.05); the filling error rate of blood transfusion reaction, which fell from 2.69% to 0.88% (χ2 = 22.20, P < 0.05); and the filling error rate of surgical complications, which fell from 2.33% to 0.88% (χ2 = 43.66, P < 0.05). However, some data of HQMS have not shown significant improvement after rectification. Conclusion. The standard and accurate filling of the first page of the medical record is the important in guaranteeing and ensuring the quality of the HQMS data; the correct filling of information in the first page of the medical record plays a positive role in improving the quality of the HQMS data.

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