Evaluation and Analysis of the Quality of Medical Records in Tertiary General Hospitals in Inner Mongolia Autonomous Region

Abstract

Objective. To have preliminary knowledge of the current quality of the medical records in the Inner Mongolia Autonomous Region by evaluating and checking medical records, summarize and analyze existing problems, and provide guidance for future control over the quality of medical records. Method. Randomly extracting 250 medical records from 25 tertiary general hospitals in the whole region, wherein 50 copies are death medical records, 100 copies are cases with operations above class B in the surgery department and 100 copies are intractable or critical medical records in internal department. The quality of the extracted medical records in ten specialties is evaluated by ten medical associated professional specialists, and the evaluation result is reviewed by management specialists. Result. A total of 138 copies are class A medical records, accounting for 55.2%, 108 copies are class B medical records, accounting for 43.2%, and 4 copies are class C medical records, accounting for 1.6%. Conclusion. The class A medical record has a lower occurrence rate, and the overall medical record writing level is unsatisfactory. Therefore, the existing quality defects are summarized and analyzed and rectification measures are provided in order to continuously improve the quality of the medical records in the whole region.

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