Đánh giá chất lượng ghi chép hồ sơ bệnh án điều trị nội trú của điều dưỡng tại Bệnh viện Bỏng Quốc gia năm 2020

Abstract

Objective: Describe the quality and factors associated with recording the medical records of nurses at the National Burn Hospital.
Subjects and methods: A cross-sectional, descriptive study with analysis to record 393 inpatients medical records of nurses at the National Burn Hospital from April 2020 to September 2020.
Result: Recording the medical record was good in 79.9% of the votes, not so good, focusing on recording the patient population (3.8%) and the health insurance card (3.1%). Diagnostic recording in the treatment department was at 87% of the votes.
Most of the items on the vital function monitoring sheet were well documented (from 90.5% to 96.7%), the part of nurses signed and signed up was only 84.1%. Most of the contents of the health care form were well and fully recorded (98.5% to 97.9%). 77.1% of the votes for public inpatient medical services were recorded well. 77.7% of the regression monitoring boards were well recorded. Department of Pediatric Burns treatment recorded the contents of the health care form correctly and achieved the highest rate (p < 0.05), the best record in other forms was the Wound Healing Center (p < 0.01). Nurses under 5 years working in the exam recorded the contents of the health care form was the highest correct rate with 75% of votes.
Conclusion: Most of the administrative procedures of medical records and the nursing cards are recorded fully and in accordance with regulations. The contents were not done well such as data cards about health insurance, full name and address of the patient's family, the patient's subject, the name of the medical staff, the sign of the patient's family, health education contents. Record good records mainly in some departments such as: Wound Healing Center, Department of Pediatric Burns, Department of Adult Burns. The quality of medical records recording is not commensurate with the number of years of experience in nurses.