Analysis of the Quality Defect from Inpatient Medical Records in a Hospital

Objective To identify appropriate countermeasures,so as to raise the medical quality through analysis of medical quality defects distribution.Methods 1 862 cases of in-patients were randomized for the investigation.4 experts are organized to review the quality of medical records to analyze the main problems and its causes.Result There are 110 defects in implementing system,198 defects in diagnosis and treatment quality,3 106 defects in the writing quality of medical records.Conclusion Hospital quality management has not done enough in place,and content quality to be improved.In order to elevate the medical quality,it is suggested to train doctors in the medical record,enhance quality control in every medical procedure,and establish a scientific doctor estimation system.