Quality control effect of quality control management measures based on zero defect management theory on surgical data on the first page of inpatient medical records

HUANG Yiming; JIANG Yongji; JIN Lei

doi:10.3969/j.issn.2095-8331.2025.06.004

Abstract：Objective To explore the effect of quality control measures based on zero defect management theory on the quality control of surgical data on the first page of inpatient medical records.Methods A cluster sampling method was used to select 1308 pieces of surgical information on the first page of inpatient medical records at Suzhou Municipal Hospital from January 2024 to December 2024 for study.The patients were divided into two groups based on management methods:the control group received routine management,and the observation group received quality control management based on zero defect management theory.The first page qualification rate,surgical code accuracy,main diagnosis and main surgical situation,other surgical omission items,and other surgical omission departments of surgical related inpatient medical records of the two groups were compared.Results The qualification rate of the first page of surgery related inpatient medical records as well as the accuracy rate of coding other operations and major operations in the observation group were higher than those in the control group(P<0.05).The accuracies of main diagnosis,main operation,main diagnosis code and main operation code in the observation group were higher than those in the control group(P<0.05).There was no missing filling in the observation group,and the number of missing filling in the main operation and other operations was lower than that in the control group(P<0.05).The numbers of other surgical missing filling departments and missing filling copies in the observation group were lower than those in the control group(P<0.05).Conclusion Quality control management measures based on zero defect management theory can improve the quality of surgical data on the first page of inpatient medical records,and is conducive to improving the integrity of surgical data on the first page of inpatient medical records.