病案质控评估系统降低病案缺陷的效果观察

Objective This study aims to observe the effect of the medical record quality control and assessment system in reducing medical record defects. Methods A total of 120 medical records admitted to our hospital from October 2024 to October 2025 were included in this study. These records were divided into two groups based on whether the medical record quality control assessment system was adopted: the basic group(60 cases without the use of the system) and the application group(60 cases using the system). The aim was to investigate the effect of this system on reducing medical record defects. Results The comparison results of defect situations in the two groups showed that the rates of incomplete/faulty filling, etc. in the basic group were significantly higher than those in the application group, and the differences were statistically significant(P<0.05), while there were no statistically significant differences in the errors of typos/grammatical mistakes, record of disease course, and coding between the basic group and the application group(P>0.05). Compared with the overall incidence rate of case defects in the basic group(30.00%), the incidence rate in the application group(6.67%) was significantly lower, and the difference was statistically significant(P<0.05). The quality control compliance rate of the application group's medical records(95.17%) was significantly higher than that of the basic group(75.00%), and the difference was statistically significant(P<0.05). Compared with the time spent on case quality control in the basic group(19.32±2.36) minutes and the time spent on file organization(3.12±0.29) minutes, the time spent on case quality control in the application group(4.56±3.52) minutes and the time spent on file organization(1.56±0.31) minutes were significantly shortened, and the differences were statistically significant(P<0.05). The quality case rate of the application group(90.00%) was significantly higher than that of the basic group(63.33%),and the difference was statistically significant(P<0.05). Conclusion This study has found that the application of the medical record quality control assessment system not only helps to reduce the defect rate of medical records, improve the quality of medical records, and save time for record organization and accusation, but also facilitates the upgrading of ordinary and low-level medical records(Grade B and Grade C medical records) to high-level medical records(Grade A medical records). It is worthy of wide promotion.