Wu Yuju, Zhou Huan, Ma Xiao, Shi Yaojiang, Xue Hao, Zhou Chengchao, Yi Hongmei, Medina Alexis, Li Jason, Sylvia Sean
Department of Health and Social Behavior, West China School of Public Health and West China Forth Hospital, Sichuan University, Chengdu, Sichuan, China.
Department of Health and Social Behavior, West China School of Public Health and West China Forth Hospital, Sichuan University, Chengdu, Sichuan, China
BMJ Qual Saf. 2020 Jun;29(6):491-498. doi: 10.1136/bmjqs-2019-009890. Epub 2019 Nov 27.
Medical records play a fundamental role in healthcare delivery, quality assessment and improvement. However, there is little objective evidence on the quality of medical records in low and middle-income countries.
To provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China.
A sample of 207 township health facilities across three provinces of China were enrolled. Unannounced standardised patients (SPs) presented to providers following standardised scripts. Three weeks later, investigators returned to collect medical records from each facility. Audio recordings of clinical interactions were then used to evaluate completeness and accuracy of available medical records.
Medical records were located for 210 out of 620 SP visits (33.8%). Of those located, more than 80% contained basic patient information and drug treatment when mentioned in visits, but only 57.6% recorded diagnoses. The most incompletely recorded category of information was patient symptoms (74.3% unrecorded), followed by non-drug treatments (65.2% unrecorded). Most of the recorded information was accurate, but accuracy fell below 80% for some items. The keeping of any medical records was positively correlated with the provider's income (β 0.05, 95% CI 0.01 to 0.09). Providers at hospitals with prescription review were less likely to record completely (β -0.87, 95% CI -1.68 to 0.06). Significant variation by disease type was also found in keeping of any medical record and completeness.
Despite the importance of medical records for health system functioning, many rural facilities have yet to implement systems for maintaining patient records, and records are often incomplete when they exist. Prescription review tied to performance evaluation should be implemented with caution as it may create disincentives for record keeping. Interventions to improve record keeping and management are needed.
医疗记录在医疗服务提供、质量评估与改进中发挥着基础性作用。然而，关于低收入和中等收入国家医疗记录质量的客观证据很少。
对中国农村医疗机构门诊医疗记录的质量进行公正评估。
选取中国三个省份的207家乡镇卫生机构作为样本。未事先通知的标准化患者（SP）按照标准化脚本向医疗机构工作人员就诊。三周后，研究人员返回各机构收集医疗记录。然后利用临床互动的音频记录来评估现有医疗记录的完整性和准确性。
在620次SP就诊中，找到了210份医疗记录（33.8%）。在找到的记录中，超过80%包含基本患者信息以及就诊时提及的药物治疗，但只有57.6%记录了诊断信息。记录最不完整的信息类别是患者症状（74.3%未记录），其次是非药物治疗（65.2%未记录）。大多数记录的信息是准确的，但某些项目的准确率低于80%。是否保存任何医疗记录与医疗机构工作人员的收入呈正相关（β 0.05，95%置信区间0.01至0.09）。设有处方审核的医院的工作人员记录完整信息的可能性较小（β -0.87，95%置信区间 -1.68至0.06）。在是否保存任何医疗记录以及完整性方面，还发现了疾病类型的显著差异。
尽管医疗记录对卫生系统运作很重要，但许多农村医疗机构尚未实施患者记录保存系统，并且记录即便存在也往往不完整。与绩效评估挂钩的处方审核应谨慎实施，因为它可能会对记录保存产生抑制作用。需要采取干预措施来改善记录保存和管理。
