Effect of Step-by-step Quality Control on the Quality of Electronic Medical Records

Abstract

AbstractObjective. To explore the effect of step-by-step quality control on the quality of electronic medical records. Method. To randomly extract 6,200 final medical records generated from July 2012 to December 2012 and 6,200 electronic medical records generated from January 2013 to June 2013, after step-by-step quality control is implemented in the network, to track the quality of the final medical records after step-by-step quality control. The final medical records are checked and evaluated according to the Basic Criterion of Documentation of the Medical Record issued by the Ministry of Health; the quality of medical records, defects in real-time, and writing defects are analyzed statistically. Results. Compared with the medical records generated from July 2012 to December 2012, the rate of grade A medical records generated from January 2013 to June 2013 is increased by 4.46% (P < 0.01), the rate of grade B medical records is decreased by 4.43% (P < 0.01), and the rate of grade C medical records is de...