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《Chinese Medical Record》 2012-03
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The Countermeasures of Improving Connotation Quality of Medical Records Writing

Jiang Dongping,Liu jie,No.313 Hospital of the PLA,Huludao 125000,Liaoning Proving,China  
Objectives Through analysis on evaluation results of medical records,this article discusses the countermeasures of connotation quality of medical records.Methods 77 hospitalization medical records in August are randomly selected which were examined according to final quality control evaluation standard and had classification and summary.Results Medical records of class-A are 65 taking up 84.4%;class-B are 12 taking up 15.6%;none of them are class-c.There are 322 defects in these medical records,in which content defects are 272 taking up 84.4%;time limit defects are 36 taking up 11.3%;front page and other defects are 14 taking up 4.3%.Conclusions Writing defects of medical records are mainly content defects in our hospital.The level of content writing of medical records reflects connotation quality of medical records,which is the key to medical quality management.How to improve connotation quality of medical records writing is worth to be discussed.
【CateGory Index】: R197.3
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【Citations】
Chinese Journal Full-text Database 1 Hits
1 Liu Yuqi,Duan Huijuan,Wang Xiaoxia,Gu Fengjun,302 Hospital of PLA,Beijing 100039,China;Application of Informatization in Medical Record Quality Control[J];Chinese Medical Record;2011-02
【Co-citations】
Chinese Journal Full-text Database 3 Hits
1 Zou Hongjie,Heilongjiang Infectious Diseases Hospital,Ha'erbin 150500,Heilongjiang Province,China;Techniques and Application of Entering and Checking of the Front Sheet of Medical Records[J];Chinese Medical Record;2011-08
2 MA Yan-ling,SUN Tao.(Department of Medical Records,The Aerospace Central Hospital,Beijing 100049,China);FULL PROCESS QUALITY CONTROL IN QUALITY CONTROL OF MEDICAL RECORD[J];Modern Preventive Medicine;2011-22
3 Li Xiaoling,Jiang Dongping,Liu Jie,Medical Department of 313 Hospital of PLA,Huludao 125001,Liaoning Province,China;Practice of Construction of Medical Record Quality Control System[J];Chinese Medical Record;2012-04
【Secondary Citations】
Chinese Journal Full-text Database 2 Hits
1 Chen Aijuan.Department of Quality Control,411 Hospital of Chinese PLA,Shanghai,200081 Zhuo Anshan.Respiratory Department,411 Hospital of Chinese PLA,Shanghai,200081;Strengthening the Standardized Management to Improve the Content Quality of Medical Records[J];Chinese Medical Record;2010-01
2 Du Hongqiao,Ma Jun,Tong Xinghai,Chen Shudu.Shanghai Changning District Maternal and Child Health Hospital,Shanghai 200051;My Opinion on the Quality of Medical Records[J];Chinese Medical Record;2010-03
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