Analysis of Deficiencies and Risk Factors in the Completion of the Inpatient Medical Record Front Page in the Intensive Care Unit

HUANG Hongyan; MENG Shujing

doi:10.13919/j.issn.2095-6274.ZHJY202505021

Abstract：Objective To systematically analyze the types and distribution characteristics of deficiencies in the data of the inpatient medical record front page in the Intensive Care Unit(ICU),and to thoroughly explore the independent risk factors leading to these deficiencies,thereby providing an evidence-based basis for implementing precise quality control.Methods A retrospective quality control review was conducted on 524 inpatient medical record front pages from the ICU of Fuquan First People's Hospital between January 2022 and January 2025.Com-pare deficiency rates across different characteristic groups,and a binary Logistic regression model was employed to analyze independent influencing factors for front page deficiencies.Results A total of 200 medical records with deficiencies were detected,resulting in an overall deficiency rate of 38.17%.The main types of deficiencies were diagnosis-related(42.20%)and procedure/intervention-related(29.03%).Multivariate Logistic regression analysis revealed that shorter healthcare professional work experience,patient admission in the first or fourth quarter,longer hospital stay,and undergoing surgery or receiving ventilator therapy were independent risk factors for front page deficiencies.Among these,work experience<5 years(OR=4.22,95%CI:2.80～6.37)and patient use of a ventilator(OR=4.53,95%CI:2.15～9.54)had the highest effect values.Conclusions The completion of the ICU medical record front page in our hospital exhibits significant deficiencies,which result from the combined effects of multi-ple factors including the criticality of the patient's condition,insufficient experience of healthcare staff,and specific busy periods.It is recommended to subsequently develop targeted improvement strategies focusing on complex cases and junior staff,strengthening management during busy periods,and other dimensions to comprehensively enhance the quality of front page data.