2013•Medical Innovation of ChinaRequires access
Analysis on the Quality Defect on Medical Records of Pediatric Inpatient
Liu Zhi-yin
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Abstract
Objective:To improve the quality of medical records of pediatric inpatients and to guarantee the records' accuracy and safety. Method: The quality control data of 1059 medical records of pediatric inpatients in our hospital from October 2011 to June 2013 were statistically analyzed,the quality defects of the medical records were divided into two categories:standard regulatory defects and content quality defects. Summarized and analyzed the apparent quality defects of medical records. Result:The quality control results of 1059 pediatric medical records indicated content quality defects, these results were compared with standard regulatory defects,statistical significance was revealed(P0.01). Conclusion:Pediatric medical records are adequate to the requirements for Hasic Norms of Medical Records according to format specification and regulation,but the level of content quality does not improve accordingly. To achieve continuous improvement of medical record quality,we still have to strengthen quality management measures.