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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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