The quality of hospital medical record review survey of primary Geriatric Hospital

Objective:In order to understand the quality of the grass-roots elderly hospital medical record written and defective factors and improve record quality targeted intervention.Methods:Randomly selected in a Geriatric Hospital were investigated retrospectively the past two years,the hospital medical record into the file,control the medical record score project,content one by one verified,and statistical analysis.Results: Sample of 95 copies of medical records,with an average score of 95.07(± 2.49) points;Grade A 98.88%,Class B 1.05%.Where 50 copies of medical records of 2010 the average score of 95.64(± 2.20) points,Grade A 100%;2011 45 copies of medical records,an average score of 94.50 points,97.78% Grade A,no significant statistical differences of two years of medical records.Conclusions: Primary hospitals Grade A higher rate of handwritten medical record review,and is not reliable,there is not enough detailed and rigorous assessment,the results difficult to reflect the true quality of the medical record,need to regulate the training of medical record writing and review,to improve the writing level,and enhance the legal awareness and responsibility case defects,prevention of illness caused by medical disputes.