Inpatient Medical Records Quality in Certain Hospital

Objective Analyzing the inpatients medical records quality defects,to formulate appropriate countermeasures,so as to raise the medical quality.Method 1862 cases of inpatients were randomized for the investigation.Four experts were organized to review the quality of medical records,and analyze the main problems and its causes.Results There are 24 defects in system implementation,30 defects in diagnosis and treatment quality,31 defects in the writing quality of medical records.Conclusions Hospital quality management has not done enough,and its connotation quality should be improved.In order to elevate the medical quality,we suggest to train doctors in the medical record,enhance quality control in every medical procedure,and establish a scientific evaluation system for the quality control of each work links.