THỰC TRẠNG CHẤT LƯỢNG GHI CHÉP HỒ SƠ BỆNH ÁN TẠI BỆNH VIỆN ĐA KHOA ĐỐNG ĐA – HÀ NỘI NĂM 2022

Abstract

Background: The medical record (MR) is an important documentation for exchanging the treatment information, scientific research, financial issue and also forensic purpose. Recently, Dong Da General Hospital has not had many in-depth studies to evaluate the quality of MR, so we carried out the study. Materials and methods: All MR of inpatient well completed the information when the patients discharging from April to June 2022 stored at the Department of General Planning according to regulations were enrolled. Tool to collect information was designed bases on Decision No. 1895/1997/QD-BYT dated September 19, 1997, 2001 on “Hospital Regulations”. 45 items are assessed pass and fail criterias. The data were processed by google sheet and SPSS 22.0. Results: There are 29/39 assessed items with criteria pass accounted for 90%, of them, 09 items with absolute score (100%). The items with a low rate of pass were: The head of department visited the patients and noted in MR accounted for (52.6%); Patients with surgery/procedure complete all necessary forms and the forms must have full signatures as prescribed (67.2%); Instructions for patients when they are discharged from the hospital (72.8%); Summary of 15 days of treatment (67.8%). Overall, the quality of MR notes pass was 81%, not pass 19%. Conclusions and recommendations: From the study results, we find that nearly 20% of MR were not qualified and met with the requirements, so it is recommended to the Department of Surgery and the Hospital to improve the management, inspection and supervision.