Problems and rectification analysis of filling in medicine expenses and treatment information on the first page of traditional Chinese medicine medical records
WANG Liqin1 GU Jing2▲
1.Department of Medical Records,Lishui Hospital of Traditional Chinese Medicine,Jiangsu Province,Nanjing 211200,China;
2.Department of Medical Records,Nanjing Gaochun District People's Hospital,Jiangsu Province,Nanjing 211300,China
Abstract Objective The Chinese medicine cost information,diagnosis and treatment information on traditional Chinese medicine medical record homepage appeared error in the logical verification.Based on the phenomenon,this study analyzes the causes of logical verification errors in the front page of traditional Chinese medicine medical records in Lishui Hospital of Traditional Chinese Medicine,and puts forward rectification measures.Methods According to the rules for filling out the first page of traditional Chinese medicine medical record homepage and comparing with the performance interface standards of national public hospitals,a logical verification report for the first page of medical records was developed in the medical record management system.The archived medical records were obtained from January 2019 to December 2020.Firstly,this study performed verification according to the treatment category and Chinese medicine fee.Subsequently,the medical institution preparations filling and medical institution preparations fees were used for verification.Finally,the rule of Chinese medicine diagnosis and treatment technology to formulate and Chinese medicine(Chinese medicine and ethnic medicine medical services)are applied for verification.The data statistically analyzed that the departments had logical verification problems and the cost of each department was logically verified wrong.Results Among all archived medical records from January 2019 to December 2020,16 departments involved logical verification problems.During this period,24 158 medical records were filed from the 16 departments of the hospital and there were logical verification errors in 5121 medical records,accounting for 21.20%.The proportion of medical records with incorrect verifications of treatment categories and hospitalization expenses was 24.51%,41.20%of the medical records filled in with medical institutions' preparations and verified with medical institutions' preparation fees incorrectly.Additionally,the medical records with incorrect diagnosis and treatment technology and Chinese medicine(Chinese medicine and ethnic medicine medical services)that was checked incorrectly was also accounted for 34.29%.Conclusion The comparison of hospitalization expenses on the first page of traditional Chinese medicine medical records in Lishui District Hospital of traditional Chinese medicine needs to be improved.It is necessary to strengthen the communication with medical insurance department and clinical department to ensure the timeliness and accuracy of hospitalization expenses comparison.At the same time,logical verification is added to the link of clinicians writing medical records,so as to improve the writing quality of medical records and reduce the revise rate of paper medical records.
WANG Liqin1,GU Jing. Problems and rectification analysis of filling in medicine expenses and treatment information on the first page of traditional Chinese medicine medical records[J]. 中国当代医药, 2022, 29(10): 155-158.
