Objective: Description of inpatient medical record management results and some influencing factors at Nha Be Dist Hospital in 2023.
Methods: A cross-sectional research design, combining quantitative and qualitative, was conducted on 3,636 inpatient medical records at the General Planning Department, Nha Be Dist Hospital, Ho Chi Minh City, Vietnam, from January 2023 to October 2023.
Results: The results of medical record management met the requirements of recording administrative information was 93.1%, recording quality of diagnosis was 95.8%, recording quality of treatment was 97.4%, recording quality care and nursing was 92.3%, and medical record preservation was 99.5%. Factors affecting the quality of medical record recording include Lack of training, supervision, inspection, and reward and punishment regulations in compliance with medical record recording.
Conclusion: The results management of medical records met high requirements for quality recording in the following contents: Administrative information, diagnosis, treatment, care, nursing, and medical record preservation (> 90%).