Statistical analysis of the quality of medical records in outpatient service

AIM: To evaluate the present situation of medical records in our outpatient service and to analyze the major factors influencing the quality of medical records in our outpatient service. METHODS: According to the standards of evaluating the quality of medical records in outpatient service, random sampling was made among 19 clinical departments of Xijing Hospital from July to October in the year of 2000. And the software SPLM was applied for the statistical analysis. RESULTS: 685 medical records out of the 730 ones were evaluated as the first rate (the score was no less than 85 points), with an average of 94.63. The well written medical records were written by senior doctors with higher professional titles, who were familiar with the rules of writing medical records and whose department set strict demands on them. CONCLUSIONS: To improve the quality of medical records in outpatient service, junior doctors and doctors here for further training should have specific training in writing medical records.