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Backgound:
In 2022, the top-tier hospital implemented the intelligent quality control system for medical record front pages. The system has essentially met the 2016 national monitoring standards for inpatient medical record front page data quality control. The hospital now aims to further enhance the quality and efficiency of its medical record quality control indicators management.
Customer pain points:
The hospital faces typical issues in medical record quality control management, such as superficial self-assessments by physicians, formalistic departmental quality control, and pressure on the medical and quality control departments. Additionally, the quality of medical record control falls below national standards.
Scope of construction:
Strictly adhere to the National Health Commission's 'Inpatient Medical Record Front Page Data Entry Quality Standards,' 'Sichuan Province Medical Record Writing Standards,' and other national and local healthcare industry quality control standards.
Ultimately, hundreds of quality control points were established, covering eight major categories of medical record content, including the medical record front page, admission, discharge, and progress notes.
Customer Value:
Through this system, automatic time-based checks are performed at the departmental level for medical record data, enabling common quality control alerts such as overdue warnings, unmet documentation requirements, and missing critical field entries. This helps reduce the occurrence of unnecessary errors in medical records and ultimately improves the quality of the records.
By leveraging Futong's medical record quality control AI capabilities and medical knowledge base, the system helps the hospital verify the accuracy of medical record front page documentation and coding, further improving the accuracy of front page data and reducing the workload of medical record coding.
At the hospital district level, for quality control points that cannot be automatically completed through information systems, quality control management is carried out through a combination of key information extraction and manual intervention.
After one month of using the medical record quality control system in four clinical departments, the average number of issues per medical record decreased from 19.01 to 8.5.
