The nursing experience of postpartum urinary retention set formed from the national situation is divided into two kinds. First, the medical record room as an independent department, and second, the merging of the medical record room and Statistics Office into a department of Medical Case Statistics room. Based on our many years of working practices, we advocate combining medical record statistics into a single department. In modern hospital management, information management is crucial, and medical records are an important source of such information. Statistics and case management represent two aspects of a whole in statistics; various data are derived from medical records. Having the Medical Record Statistics Office as a department facilitates work and reduces unnecessary conflicts. The medical record statistics office should become one of the important departments in the hospital.
The training of medical record management personnel should align with the development and requirements of modern hospital management. Case management is no longer simply about doing the custody, registration, and classification of general work but also involves comprehensive analysis of the information obtained to provide reliable support for hospital leadership. In 1981, the National Hospital Management Society and the Medical Record Statistics Conference were held in Nanjing, which highlighted the importance of medical records in hospitals involving more than 10 million people. This represents an important force within the hospital. China has yet to form a complete medical record management education and training system, which should be strengthened. On-the-job training for personnel should be provided, allowing medical record management personnel opportunities to participate in seminars and training courses of various forms to gain new knowledge and adapt to new forms of medical record management.
Assessment and inspection of medical record quality is an important part of medical record management. To ensure that medical records comply with the requirements of Class A standards, the key lies in developing quality assessment criteria. Combining pre-inspection with post-inspection evaluations for hospital medical records is necessary. Currently, after-discharge medical record inspections are retrospective examinations. To perform these inspections effectively, it is very necessary to have full-time reviewers in the medical record room. Conducting comprehensive inspections to evaluate medical record reviews may require more energy and time, but it helps identify and solve problems, ensuring the quality of hospital medical records.
The above points are combined with the practical experiences gained from our work. On July 19, 2002, the Ministry of Health issued a notice regarding the good form of medical institutions and medical regulations. I believe that through the joint efforts of all medical record management staff, our case management career will achieve faster improvement and development.