A case study of the chief inspection conclusions from physical examination reports of a Tertiary Ⅲ-A hospital in Urumqi / 中华健康管理学杂志

ABSTRACT

Objective This paper analyzed the conclusion report of physical examinations by the chief inspection physician from the Health Management Center,The First Teaching Hospital of Xinjiang Medical University in Urumqi,to examine the quality of these reports.The research aimed to provide a reference for improving the quality of the chief physician's conclusions from physical examinations.Method Using the method of blinding,three senior physicians as quality control doctors analyzed the value of concordance of 12 489 conclusions from physical examinations by seven chief inspection physicians made from September to October 2017 based on three aspects,including standardization of classified disease-diagnosis handwriting,conclusions of physical examination and sequence of positive results,and unified diagnosis.Results The results showed that value of concordance of standardization of classified disease-diagnosis handwriting of the reports by the seven chief inspection physicians was 95.2％-96.5％ and of conclusions of physical examination and sequence of positive results was 94.0％-96.1％.Additionally,these two values indicated no statistically significant differences among the seven chief inspection physician (x2=9.906,9.740respectively,P＞0.05).However,the concordance value of unified diagnosis by the seven chief inspection physicians was 86.2％-94.6％,displaying statistically significant differences among the chief inspection physicians (x2=92.990,P＜0.001).Conclusion It was concluded through the research that differences in the chief inspection physicians' reports of physical examination reached normalization and unification in aspects of standardization of classified disease-diagnosis handwriting,and conclusions of physical examination and sequence of positive results.However,statistical variations in aspects of unified diagnosis revealed that training should be conducted for the chief inspection physician for physical examination.