Articles Vol. 63 No. 4 (2022) 01/08/2022

CURRENT STATUS OF INPATIENT MEDICAL RECORDS AND SOME RELATED FACTORS AT THE GENERAL INTERNAL MEDICINE DEPARTMENT - HANOI MEDICAL UNIVERSITY HOSPITAL IN 2021

Le Minh Dat1,2, Nguyen Huu Thang3,4, Pham Hai Thanh3,4, Cao Thi Thanh Thuy5,6
1 Hanoi Medical University Hospital
2 Bệnh viện Đại học Y Hà Nội
3 School of Preventive Medicine and Public Health, Hanoi Medical University
4 Viện Đào tạo YHDP và YTCC, Trường Đại học Y Hà Nội
5 Planning and Finance Department, Ministry of Health
6 Vụ Kế hoạch Tài chính, Bộ Y tế
Corresponding author: leminhdat@hmu.edu.vn
DOI: 10.52163/yhc.v63i4.390
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Keywords
Medical record, current situation, related factors, inpatient.
Abstract

Objective: To describe the current status of inpatient medical records and some related factors at the
Department of General Internal Medicine - Hanoi Medical University Hospital in 2021.
Methods: A cross-sectional descriptive study, a study with a combination of quantitative and
qualitative, at the Department of General Internal Medicine - Hanoi Medical University Hospital.
The study selected 300 random medical records. We conducted 07 in-depth interviews and 03 focus
group discussions with medical staff.
Results: The rate of the full record of all medical records is 74,7%. We determined that the personal
factor which is the perception of medical staff about medical records affects the recording of medical
records. Influential factors identified in the study include inspection and supervision; medical record
work; training sessions or instructions on making medical records that have not been organized; there
are no suitable sanctions. The limiting factors pointed out are a large number of patients, human
resources; administrative part of the medical record.
Conclusion: The study has shown a number of factors affecting the medical record in hospitals.

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