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《Hospital Management Forum》 2012-11
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Improve Medical Record Writing Quality with Two Methods from Four Aspects

ZHOU Li-ping ZHOU Hong-zhu XIA Zhi-wei The Third Hospital of Peking University  
Medical record writing quality is the guarantee of medical quality and medical safety and the cornerstone to steady and fast development of hospital clinical medical work.However,the clinicians tend to pay little attention to the medical record writing quality and ignore the timely modification to medical record.This paper discusses the root causes of this phenomenon and puts forward corresponding management countermeasures.Conclusion Knowledge,awareness,volition and will are four influencing factors of clinicians' attitudes toward medical record writing.Medical record writing quality can be effectively improved by following measures: increasing clinicians' knowledge of medical record writing specifications through training and examination,strengthening clinicians' awareness of medical record writing through notification and inspection,affirming clinicians' volition through rewarding and punishing,developing clinicians' will to write high quality medical record and decreasing objective difficulty in medical record writing though improving objective conditions.
【CateGory Index】: R197.3
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