Title: The Rotation of Physicians in the Medical Record Department and Its Impact on the Quality of Medical Records
Abstract: Objective. To investigate the impact of a rotation system of the medical record department on the quality of medical records that were written by the participating clinicians. Methods. The quality of medical records that were written by clinicians before and after they participated in the rotation in the medical record department was contrasted, and statistical analyses were taken to confirm the change in the quality of the medical records before and after the implementation of the system. The specific method is all new clinicians in our hospital participated in the rotation in the medical record review room for at least 3 months after unified organization and arrangement. Their work was to audit discharge medical records of related clinical departments, including the signatures on the quality of discharge medical records, patients' operations involved in the medical records, invasive operations and so on, as well as the signatures on the informed consent forms and other medical record laws and regulations. Meanwhile, every physician involved in the rotation in the medical record department further performed theoretical study on the Specification of the Documentation of Medical Records in Heilongjiang Province. The medical record audit was guided by theory; the rotation physicians' understanding and mastering of the quality of the medical records, the medical record laws and regulations and other related contents were deepened by the actual work. Results. The qualified rate (81.7% vs. 95.6%) of medical record writing specifications of the clinicians before and after they accepted the rotation in the medical record department, the awareness rate (79.7% vs. 96.8%) on the medical record laws and regulations, the average score (83.7 ± 5.6 vs. 95.2 ± 3.7) on a test of knowledge on medical records, the defect rate (21.5% vs. 9.7%) of the medical records, the severe defect rate (12.3% vs. 4.1%) of medical records, the repair rate (13.7% vs. 4.6%) of the medical records before being filed, the error rate (66.7% vs. 26.7%) of the medical records involved in medical disputes and other indicators have statistical significance. Conclusion. The quality of medical records written by the clinicians who had participated in the rotation in the medical record department was significantly improved.
Publication Year: 2013
Publication Date: 2013-04-01
Language: en
Type: article
Indexed In: ['crossref']
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