Quality Analysis of 10 954 Inpatient Medical Record Front Pages in a Secondary-level Public Hospital

Abstract

Objective: To analyze the quality of inpatient medical record front pages from a secondary-level public hospital in Wuhan, Hubei province, so as to provide support for establishing high-quality front-page data. Methods: All 10 954 inpatient medical record front pages in 2024 at the hospital were audited. Compliance was evaluated per the Specifications for Data Quality of Inpatient Medical Record Front Pages. Results: Among the reviewed records, 2 937 (26.81 %) contained defects, totaling 5770 defects (average: 1.96 defects per front page). The primary issues identified in the defect analysis of medical record front pages are concentrated in the following categories with their respective frequencies: surgical/procedural information defects (27.31 %), discharge diagnosis or coding defects (22.06 %), defects in ethnicity/nationality/gender/age-related fields (17.76 %), and ID/contact information defects (13.07 %). Further analysis reveals a statistically significant correlation between high-frequency defects and specialty groups. The surgical-rehabilitation group is more prone to procedural or operational defects, while the internal-medicine group exhibits higher rates of diagnostic or coding errors, with no notable differences in basic-information defects between the two groups. Conclusions: The key issues in the hospital’s medical record front page can be resolved through three measures: enhancing training programs, advancing informatization, and improving the quality-control management system.