The Quality of Out Patient Medical Records of Health Care Service Unit in Maha Sarakham Province for the Year BE 2554 (2011) - คุณภาพเวชระเบียนผู้ป่วยนอกของหน่วยบริการสาธารณสุข จังหวัดมหาสารคาม ปี 2554

Abstract

The purpose of this research study is to evaluate the quality of out patients medical record of
Health care service of Maha Sarakham Health offices for the year 2554 (2011). The sample groups
were all hospitals in Maha Sarakham province (11 places) and Tambon health promotion hospital
30 percent of all of them (53 stations) totalling 64 sample sites. Tool using for evaluate was the out
patients medical records evaluation test which were adapted from quality evaluation test for out
patient and emergency of the office of compensation and quality of services, the National Health
Security Office, consisting of 7 major categories guidelines: 1) patient profile; 2) history; 3) physical
examination; 4) treatment /investigation; 5) follow up; 6) operative note; 7) informed consent.
In a randomly sampling, 50 patients per site were selection totalling 3,500 samples, during October
2010 - January 2011. The team work for evaluation were nurses, health specialist officer and computer
specialist 45 designated of person, divided into 5 teamwork to evaluate 2 health station per day
during 1 - 20 June 2011. Data analysis were descriptive and inference method, at the significant
level p 0.05. The result showed that during the period of evaluation and investigation 2,986 medical
treatment records (93.31%) were in place while 214 records (6.69%) were not. Of the total, there
were 2,436 records (81.58%) of 550 of the hospital medical records (18.42%). The average completeness
quality of the out patient records amounted to 62.56 percent (SD 23.93) in both types of
institution. However Tambon health promotion hospital site showed the average of 58.5 percent
(SD 23.58) and 80.46 percent in the hospital site (SD 15.93). The out patient medical treatment
records were complete and scored the highest at 1) Amphoe Na Chuek district 78.78 percent (SD
13.22) 2) Amphoe Yang Si Surat 76.26 percent (SD 9.95) 3) Amphoe Wapi Pathum 73.93 (SD 12.39
4) Amphoe Borabue 71.74 percent (SD 15.32) and 5) Amphoe Kae Dam 71.24 percent (SD 15.50).
To compare the quality of the medical treatment record between the hospital and Tambon Health
promotion hospital it was found that in all sample districts, the medical records of the hospital have
higher quality significantly than the samples from the health offices, except at Amphoe Na Chuek
and Amphoe Yang Si Surat, the medicate treatment records from the Tambon health promotion
hospital showed higher quality than the record from the hospital significantly. It is recommended
that development of the quality of health and medical service of all units should be consisting of
standards on services, medical treatment record, and health care services. 2) To develop auditing
service should be consisting of team work capability (knowledges, process and systems and personnel)
criteria and hand books for audit (Internal and external audit) 3) The development for motivations
consisting of audit team work (personality, characteristic and team work competition) services
unit (competition of MRA and services).
Key words: out patient, medical records