A Study on Loose Laboratory Reports in A Hospital

Yoo, Yeon-Soon; Ha, Eun-Hee

Journal of Korean Society Quality Assurance Health Care 1996;2(2): 46.
Published online April 30, 1996.

일개(K) 병원의 누락 조직검사결과지에 관한 조사연구

유연순¹, 하은희²

¹이화대학부속 목동병원
²이화의대 예방의학교실

A Study on Loose Laboratory Reports in A Hospital

Yeon-Soon Yoo¹, Eun-Hee Ha²

¹Medical Record Department, Ewha Womans University, Mok Dong Hospital
²Department of Preventive Medicine, College of medicine, Ewha Womans University

Abstract

Background
The medical record is a compilation of pertinent facts of a patient's life and health history, including past and present illness and treatment. It is written by the health professionals contributing to that patient's care. And the medical record is the permanent, legal document which must contain sufficient information to identify the patient, justify the diagnosis and treatment, and record the results. As such, it must be accurate and complete. So we try to analyze the medical record especially a kind of incomplete record, loose laboratory reports.
Methods
During the one-year period(from January to December 1988), a medical record practitioner examine and analyze the record of laboratory reports at K Hospital in Seoul. A total of 320 loose laboratory reports for 3,818 admitted laboratory reports. And a medical record practitioner and a physician review and analyze the influencing factors for the various reasons of clinical and laboratory aspects.
Result
The loose percentage by department is the highest in obstetrics(40.4%) but the highest loose rate is in pediatrics(25.0%). The most of omission is occurred in operation room(80.3%) than OPD(19.7%). The change of diagnosis is according to duration of laboratory and more changable in cancer patient.
Conclusion
Regular analysis of the documentation in the medical record so it fulfills its purposes of communicating patient care information. So it serves as evidence of the patient's course of illness and treatment for various legal, reimbursement, and peer evaluation review. And it is very important aspect of quality assurance in medical activities.

Key words Medical record;laboratory report;loose rate of record;