| Abstract |
Objective: In order to improve the quality of outpatient medical care and patient service, and to effectively carry out the assessment of outpatient diagnosis certificates at Inner Mongolia International Mongolian Medical Hospital, and to solve the tedious manual assessment work, a management system for outpatient diagnosis certificates has been developed. Method: Randomly select the assessment experts for diagnosis certificates in our hospital from the beginning of each month from 2021 to 2023, establish a professional committee for diagnosis certificates, and provide both paper and electronic versions of diagnosis certificates on the 5th of each month. Whether the content including name, age, gender, address, diagnosis and treatment opinion, physician signature, date, etc. is complete, in compliance with the situation and missing items. Result: A total of 960 outpatient diagnosis certificates were assessed, of which 78 had unclear address writing, accounting for 8%. 6 had age discrepancies with the electronic version, 16 had non capitalized numbers, 15 had stubs that did not match the electronic version, and 4 had diagnostic questions. Two diagnoses did not match the electronic records, 357 had electronic medical records, accounting for 37.2%. 142 medical orders were processed, accounting for 33.4%, 321 prescriptions were processed, accounting for 33.3%, and 278 examinations and tests were processed, accounting for 30%. 294 hard copy diagnosis certificate. Conclusion: The development of an outpatient diagnosis book management system can promptly screen out electronic and paper diagnosis books that do not meet the standards.
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