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医生的知识和认知对病历质量的影响。

The influence of knowledge and perceptions of doctors on the quality of medical records.

作者信息

Suti Ismawati Nining Dwi, Supriyanto Stefanus, Haksama Setya, Hadi Cholicul

机构信息

Doctoral Program of Public Health, Faculty of Public Health, Universitas Airlangga, Surabaya .

Health Policy and Administration Department, Faculty of Public Health, Universitas Airlangga, Surabaya.

出版信息

J Public Health Res. 2021 Apr 14;10(2):2228. doi: 10.4081/jphr.2021.2228.

Abstract

BACKGROUND

Medical record reflects the quality of health services provided, which is influenced by existing resources, such as the doctors in charge. This study aims to determine whether doctors' knowledge and perceptions affect the quality of the medical record.

DESIGN AND METHODS

This is a quantitative and cross-sectional study carried out at Dr. Soetomo's general and academic hospital Surabaya, Indonesia, in September and October 2020. Data were purposively obtained from a total of 45 doctors working at the hospital's inpatient service surgery ward using the questionnaire and checklist medical record quality. Furthermore, ethical clearance and doctors' informed consent were obtained, with the data statistically processed and analyzed by multiple linear regressions.

RESULTS

The results and conclusion showed that doctors' knowledge and perceptions of the quality of medical records were influence to medical record quality (p<0.05).

CONCLUSIONS

Hospital management needs to regularly increase doctors' knowledge and perceptions by socializing and monitoring medical records.

摘要

背景

病历反映了所提供的医疗服务质量,其受到现有资源的影响,比如主管医生。本研究旨在确定医生的知识和认知是否会影响病历质量。

设计与方法

这是一项于2020年9月和10月在印度尼西亚泗水苏托莫博士综合学术医院开展的定量横断面研究。通过使用问卷和病历质量检查表,有目的地从该医院住院服务外科病房工作的45名医生处获取数据。此外,获得了伦理批准和医生的知情同意,数据经统计处理并通过多元线性回归进行分析。

结果

结果和结论表明,医生对病历质量的知识和认知对病历质量有影响(p<0.05)。

结论

医院管理层需要通过宣传和监督病历,定期提高医生的知识和认知。

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本文引用的文献

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Impact of an educational intervention on medical records documentation.一项教育干预对病历记录的影响。
World J Emerg Med. 2018;9(2):136-140. doi: 10.5847/wjem.j.1920-8642.2018.02.009.
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Improving the medical records department processes by lean management.通过精益管理改进病历部门流程。
J Educ Health Promot. 2015 May 19;4:48. doi: 10.4103/2277-9531.157244. eCollection 2015.

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