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《Chinese Medical Record》 2010-02
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Analysis of the Quality Control of Medical Records by Reviewing 40 Archive records

Yang Feng,Pang Liangying,Lin Yueqiong.The Affiliated Hospital of Guangdong Medical College,Zhanjiang,524001  
Objective To improve quality control of medical records and enhance health professionals' consciousness of law and self-protecting.Methods 40 archive records owing to medical disputes from 2002 to 2008 were analyzed in our hospital.Results Most medical disputes occurred at departments of bone surgery,obstetrics and gynecology,and brain-surgery than other departments.The primary causes of medical disputes were lack of communication and skyscraping expectations.Illegible font,altered or wrong writing,and leaked items-filling were main problems in the quality of archive records.Conclusion The medical industry is a industry at high risk,especially departments of bone surgery,obstetrics and gynecology,and brain-surgery.Therefore,medical staffs,not only need to enhance their operational capacity,but also make good physician-patient relationship and write medical records according to the provisions,in order to avoid the occurrence of medical disputes.
【CateGory Index】: R197.3
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