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《Chinese Medical Record》 2012-01
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Analysis and Countermeasures of Quality Defects Reasons of Running Medical Records

Xu Shaoyin,Zhou Ping,Sun Rongrong,Medical Department,Nanjing Gulou Hospital,Nanjing 210008,China  
Medical records quality reflects medical quality management level of hospital,management level of clinical department and clinical professional level of physician.We selected a surgery department whose class-A rate of writing quality of medical records is in the last place for three years in hospital,having segment quality control and analyzing factors affecting medical records quality.985 copies of medical records in this department are selectively examined.It shows that factors affecting medical records quality are judicial knowledge about medical records of clinical physicians,quality management of clinical departments and organization allocation of medical groups.Therefore,hospital and department should strengthen legal consciousness of medical staffs and management to subordinate physicians and perfect echelon construction of medical groups,through electronic medical monitoring system to reduce medical records defects and improve medical records quality.
【CateGory Index】: R197.3
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