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| Implementation of quality control in medical record management |
| ZHANG Jiandong |
| Department of Quality Control, Zhaoqing First People′s Hospital, Guangdong Province, Zhaoqing 526020, China |
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Abstract Objective To explore and analyze the implementation effect of quality control in medical record management. Methods Zhaoqing First People′s Hospital began to implement quality control in medical record management since January 2020. A total of 1150 medical records of each clinical department before the implementation of quality control from January to December 2019 were selected as the reference group, and 1100 medical records of each clinical department after the implementation of quality control from January to December 2020 were selected as the study group. The quality grade distribution of medical records and the occurrence of defects in medical records were compared between the two groups. Results The proportions of class A, class B and class C medical records in the study group were 92.45%, 6.27% and 1.27% respectively. The proportions of class A, class B and class C medical records in the reference group were 84.87%, 9.74% and 5.39% respectively. The quality of medical records in the study group was better than that in the reference group, and the difference was statistically significant (P<0.05). The incidence of defects in the medical records of the study group was 2.00% (22/1100), which was lower than 6.78% (78/1150) of the reference group, and the difference was statistically significant (P<0.05). Conclusion The implementation of quality control in the management of medical records can effectively reduce the incidence of defects in medical records, help to improve the quality level of medical records, and improve the overall quality of medical record management.
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