일개 교육병원에서 의무기록의 충실도의 대한 조사 |
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박석건1, 김홍태1, 김광환2, 서순원1 |
1단국대학교병원 의무기록위원회 2단국대학교병원 의무기록과 |
Survey of completeness of medical records in one educational hospital using new checklist |
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Seok Gun Park1, Heung Tae Kim1, Kwang Hwan Kim2, Sun Won Seo1 |
1Medical record committee, Dan Kook university hospital 2Medical record department, Dan Kook university hospital |
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Abstract |
Background Medical records thought to be reflecting the quality of medicine. By this ground, examination of medical records can be served to evaluate, and to improve the quality of medical care. To examine the medical records, we need some standards or checklists which can be used to sort out the problems. Methods We developed checklists for medical records evaluation. We studied 1,677 medical records about its completeness using this checklists in one educational hospital. Survey was completed by 5 well trained staffs of medical record department. Results are analyzed. SPSS/PC+ program was used for statistics. Results 13.8% of discharge summary was incomplete. Recording of the demographic information was also poor in incomplete medical records compared to complete ones. Progress note was recorded average 4.16 times during 11.9 hospital days. After 4th hospital day, recording rate of progress note dropped sharply. Rate of professor's signature on operation records was poor(27%). He or she who described the discharge summary well also wrote progress note well. Conclusions Fill-up of demographic date should be stressed during medical record education program. Strategy to create the environment emphasizing the responsibility of professor on quality medical record should be made. We suggest new index (number of records/hospital stay) for the evaluation of completeness of progress note. |
Key words
medical records;QA;progress note;completeness of medical recording; |
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