Analysis on Quality of 440 Medical Records from Seven Hospitals

Objective To analyze the problems in medical record writing so as to provide facts for the improvement in medical record writing's quality.Methods From seven hospitals,440 medical records were drawn out at random,and then were checked item by item according to relevant criteria.Results Among the 440 medical records,92.5% belonged to grade A,7.5% to grade B,and none to grade C.The rate of grade A was 91.4% in surgical system and 93.6% in internal medicine system.Among the death medical records, the rate of grade A accounted for 87.8%,while it was 97.1% in leaving-hospital records.Conclusion It is the key to the improvement in medical record quality to take up a proper attitude or strengthen responsibility.