Analysis and Recommendations on Written Defects of Hospital Records

ObjectiveTo investigate written defects of hospital for targeted improvement.MethodBased on evaluation form of inpatient medical records in the evaluation standards for clinical basis quality in medical organization of Shaanxi Province,the quality inspection and evaluation was performed for running and terminal medical records.ResultFrom September 2009 to December 2010,a total of 2,113 medical were evaluated;among which hospital had 736 defects,accounting for 34.83%.Among them,the complaints describe had defect in 104 records(4.92%);53 present history writings had defects(2.51%);separation of chief complaint,present history and main diagnostic appeared in 36 records(1.7%);initial and(or) admission diagnosis was not complete in 139 records(6.58%).ConclusionHospital functional management departments should strengthen writing skills training of medical in young physicians and enhance responsibility of teacher and director to improve quality of medical records.