Quality Development of Medical Records of Nam Kliang Hospital, Nam Kliang District, Si Sa Ket Province

Abstract

This quality development of medical records was aimed at developing the information in medical records of out and in patients with the proportion of completion of more than 85 percent and shall reducing number of complaints at least 5 cases per year. The descriptive study included 10 percent of medical records of both in- and out- patients on regular basis percent monthly, within the fiscal years, 2009-2012 by simple random sampling for an evaluation under the criteria for assessment on comprehensiveness and completion of medical records of the National Health Security Office (NHSO) and Healthcare Accreditation Institute (HA). The model of quality development with continuity under the Deming Cycle with Plan-Do-Check-Act (PDCA) was adopted for finding solutions on missing pieces identified in an analysis.

During 2009 - 2012, external evaluators (NHSO, 10th region) reported the comprehensiveness and completion of information of outpatients' medical records of 81.01, 87.19, 89.78 and 92.07 percent respectively, while the comprehensiveness and completion of information of inpatients' medical records of 78.38, 82.24, 89.98 and 93.43 respectively. Based on the analysis, it implies that it was effective problem-solving, covering aspects of process, personal and equipment. The competency with accountability of recorders was increasing with compatibility and in compliance with all criteria on evaluation, of medical records of both in- and out- patients.

The results of this development lead the development of recording of information in medical records of the Nam Kliang Hospital, Si Sa Ket province. As a result, the improvement of quality of medical treatment for patients should be expected with reduction of complaints on quality of medical service, including the increasing budget allocation from the NHSO with response to higher Case Mix Index (CMI) and a rewarding sum as past of the Pay for Performance (P4P).