Quality Defects Analysis and Continuous Improvement of Terminal Medical Record

Objective Through quality defect analysis on terminal medical records,the problems in quality of care can be found,and it benefits on the implementation of continuous improvement,and improves health care quality,ensures patient safety.Method Inpatient terminal medical record in different departments of the year 2012 were random checked according to 10% of the proportion in a hospital. The related standards were used for audit evaluation,statistical analysis was performed on medical quality defects. Result The quality of awareness was not strong,connotation quality of medical records needed to be improved,and some department heads had no strong sense of responsibility. In this regard,the hospital caught from persistent awareness education,strengthen quality control of medical records throughout the implementation of incentive and other three aspects of the continuous improvement. Implementation of measures improved the quality of medical records,and improved medical quality standards.