Grid management for improving data quality control on the front page of inpatient medical records / 现代医院

ABSTRACT

Objective To enhance the data quality of the front page of inpatient medical records.Methods Ten coders were engaged to perform manual quality control,and system verification rules were integrated for the basic information,diagnosis,treatment information,and hospitalization process information on the front page of inpatient medical records before and after the implementation of grid management.Results A total of 808 defects were found on the front pages of 728 inpatient medical re-cords.Among these deficiencies,basic information,diagnosis and treatment information,and process information accounted for 40.84％,3.96％,and 55.20％respectively.Totally,282 defects on the front pages of the 796 inpatient medical records man-aged under grid management.Among them,basic information,diagnosis and treatment information,and process information ac-counted for 39.00％,7.80％,and 53.19％,respectively.The overall defect rate was significantly decreased under grid manage-ment compared to the rate without it,(x2=6.553 5,P＜0.05).After the implementation of grid management,the numbers of the defects in admission condition,ID number incompletion,incision healing status,and coding were significantly decreased(P＜0.05).After the normalized coding of the ID number,the defect in ID number incompletion on the pages disappeared con-sequently.Conclusion Grid management reduces communication and feedback time,improves the data quality of the front page of inpatient medical records,and enhances problem-solving efficiency.It is important to coordinate the control of the data on the front pages of inpatient medical records to enhance standardization,consistency,and integrity.Moreover,it can also be applied to other areas of hospital management,offering scientific methods to optimize overall hospital operations.