Effect of Standardization of Medical Record Management / 现代医院

ABSTRACT

Objective To identify the problems of medical record management standardization in clinical case management for the study of medical record quality and give some corresponding measures.Methods 3,000 medical records of patients in our hospital from January 2015 to December 2016 were collected and divided into control group (with 1,500 records from January 2015 to December 2015) and observation group (with 1,500 clinical medical records from January 2016 to December 2016).The control group adopted regular data management while the observation group employed standardized lean management.Medical record defects, rectification rate and the average scores of inpatient medical records between the two groups were compared and analyzed.Results The average score of inpatient medical records in observation group was significantly higher than that of the control group (t=13.672, P<0.05), while the defect degree and the modification rate of the medical records were significantly lower than those of the control group (P<0.05).Conclusion Standardized medical record management contributes to the improvement of the quality of medical records.