Quality Improvement of Inpatient Medical Records in Yasothon Hospital

Abstract

Abstract

 This action research aims to improve the quality of inpatient medical records in Yasothon Hospital. Selection of the operation area and the sample group for the specific development (Perposive Sampling). The sample group was the Medical Record Quality Development Committee of 33 people. Quantitative data was collected using the Medical Record Audit Guideline 2020. of the National Health Security Office (NHSO). Descriptive statistical data were analyzed, including percentage, mean, standard deviation. Compare mean scores using Z-test Statistic qualitative data. using an in-depth interview group discussions, observations, meeting notes perform content analysis. The study found that The development of inpatient medical record quality in Yasothon Hospital consisted of a 9-step process: 1) a study of the context of the quality of medical record recording problems; ) Implementation according to the plan 5) Supervision follow-up 6) Evaluation of the quality improvement of inpatient medical records 7) Comparison of results 8) Organizing a forum to exchange knowledge 9) Summarize the development according to the steps. Quality development process Recording of medical records for inpatients of Yasothon Hospital, including training to educate the committee on assessment criteria and those who are interested. According to the 2020 medical record quality assessment manual, a workshop was organized to obtain an action plan for problem solving. Summary of the process Participants gained knowledge according to the assessment criteria. That is, before the training, 60 percent had moderate knowledge, after the training, 64 percent of the committee members had good knowledge and 32 percent had very good knowledge, and the process for improving the quality of medical record recording was obtained in 4 urgent criteria out of a total of 12 criteria. The evaluation is Criterion 3 Inform Consent is Criterion 4 History Criterion 5 Physical Exam Criterion 7 Consultation Record It can be seen that after the development there is an increase from the original 50.33 percent 55.78 71.29 77.78 according to The order of increase was 79.72%, 71.38, 76.49 and 58.02. From the data, it can be seen that criterion 7 Consultation Record has decreased percentage. which is an opportunity for further development. The success factor is the extension from the committee to those involved in the medical record recording. Promote participation in integrated development Strengthen incentives to improve the quality of medical records with more stakeholders.