Predictability of the completeness of medical recording of quality of care for inpatients

Park, Un Je; Park, Eal Whan

Journal of Korean Society Quality Assurance Health Care 1997;3(2): 60.
Published online March 30, 1997.

의무기록 완성도의 입원환자 진료적정성에 대한 예측도 평가

박운제¹, 박일환²

¹단국대학교 QA팀
²단국대학교 가정의학과

Predictability of the completeness of medical recording of quality of care for inpatients

Un Je Park¹, Eal Whan Park²

¹Department of QA, Dankook University Hospital
²Department of Family, Medicine Dankook University Hospital

Abstract

Background
Medical records are used to assess clinical performance of physicians and quality of care. The contents which are written in medical records are considered as the objective evidences to know what the doctors think about the patient's problems. But the problem to use medical records as the assessment tools is the incompleteness of medical recording. The purpose of this study is to know if the completeness of medical recording is correlated to quality of care for inpattients and it can predict physicians's quality of care. Method : 32 clinical physicians reviewed 200 patients' medical records who were selected randomly from the inpatients who were admitted to the university hospital during July, 1995 and June, 1996. The reviewers used the structured evaluation questionnaires which were composed of two part. One part evaluated the completeness of the medical recording and the other evaluating appropriateness of diagnosis and treatment processes. We summated the scores of each items and calculated percentile scores.
Results
The mean percentile score of completeness of the medical recording was 67.9% in 1995 and 79.8% in 1996. The mean percentile score of appropriateness was 52.2% in 1995 and 69.5% in 1996. This change between 1995 and 1996 was statistically significant. In non-surgical patients, the percentile scores of the completeness and those of the appropriateness were correlated positively and this correlation was statistically significant(p<0.05). In surgical patients, the positve correlation between the completeness and the appropriateness was also statistically significant(p<0.05). Discussion : In conclusion, the completeness of medical recording is considered as the good predictor of the quality of care for inpatients.

Key words completeness of medical recording;quality of care;inpatient;