Status of recording inpatient medical records by nurses at Hai Duong General Hospital in 2022

Tóm tắt

Objectives: To describe the current status of medical records by nurses in select clinical departments at Hai Duong General Hospital in 2022. Methods: A cross-sectional study was conducted among 402 medical records from 4 internal medicine departments and 4 surgical departments at Hai Duong General Hospital in April 2022. Results: The percentage of satisfactory medical records was found to be 84.1%. Conclusion: The current status of medical records in certain clinical departments at Hai Duong General Hospital was quite good. Further research and improvements in documentation forms and practices are necessary to enhance the quality of medical records.