THỰC TRẠNG CHẤT LƯỢNG HOÀN THIỆN CÁC BIỂU MẪU TRÊN HỒ SƠ BỆNH ÁN ĐIỆN TỬ TẠI BỆNH VIỆN HÙNG VƯƠNG GIA LAI: KẾT QUẢ BƯỚC ĐẦU TRƯỚC CAN THIỆP (T0)

Abstract

Objectives: To describe, as preliminary baseline findings, the quality of form completion in electronic medical records (EMR) at Hung Vuong Gia Lai Hospital, informing intervention content for the project “Effectiveness of bedside case review combined with departmental scientific activities”.

Subjects and methods: A cross-sectional descriptive analysis of preliminary pre-intervention (T0) data from 89 unique inpatient EMRs; the protocol-specified target sample is 155 EMRs per time point, so this dataset is preliminary and not yet locked. Each EMR was assessed using four checklists (54 criteria total): nursing care monitoring (20 criteria), infusion monitoring (5 criteria), disclosure of medications/supplies/services (6 criteria), and health-insurance-related documentation (23 criteria), scored 0/1/2/Not-applicable. An EMR met requirements when the overall score was ≥80% and every applicable checklist also scored ≥80%.

Results: The mean overall score was 89.6±6.6%, yet only 29/89 EMRs (32.6%) met the requirement definition; 87/89 (97.8%) reached an overall score ≥80%. The nursing care monitoring checklist scored lowest (74.8±15.7%; 33.7% of records met threshold), with the weakest areas being “care diagnosis/problem and goals” (63.3%) and “care intervention” (66.2%) - identified as priority content for intervention. The other three checklists scored high: infusion 98.8%, medication/supply disclosure 97.8%, and health-insurance documentation 100% of applicable records reaching ≥80%.

Conclusion: A high aggregate score can mask a gap concentrated in one specific form group. These are preliminary findings (n=89/155); the dataset still contains some data-quality issues requiring review before being locked as the baseline for subsequent intervention phases.