Thực trạng ghi chép hồ sơ bệnh án nội trú tại Bệnh viện Phổi tỉnh Sơn La năm 2020

Abstract

This cross-sectional study examined and assessed the quality of 217 inpatient medical records from the Lung Hospital of Son La between January 2020 and August 2020. The results showed that most (97.7%) of the medical records were completed satisfactorily, of which the lowest completed section was the record summary section (79.3%). When evaluating each section of the records, only 59.9% had full information of the patient's occupation, 71.9% had incomplete or blank administrative section. The diagnosis section was completed in only 63.1% of the records, and 24.9% had no information on hospital discharge status. Clearly, priority should be given to monitoring and correcting the process of filling in medical records to further enhance the quality of records for future assessment.