ANALYSIS OF THE RESULT OF QUALITY MONITORING OF MEDICAL RECORDS WITH COMPUTER(A REPORT OF 7 961 CASES)

Objective To analyze the cause of existing problems by monitoring the medical records with computer;find the corresponding solution and improve the quality of medical records.Methods The quality of 7 961 medical records was monitored by using computer procedure;analyzed the problems that existed in the medical records.Results Each medical record had various degree problem;the first page defects of medical record were most,accounting for 28.9% and the medical order defects were least,accounting for 4.2%.It reflected that doctor paid less attention to the medical record.Conclusion Strengthening the concept of law and the training of the writing standard of medical record,paying attention to medical record writing,doing well the quality controlling by senior doctors and perfecting the system of quality controlling of medical record is the key to improve the quality of medical records.