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《Chinese Medical Record》 2012-05
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Final Quality Control of 1144 Copies of Hospitalization Medical Records

Xu Hongmei,Liu Zhuo,Tan Yanfang,The General Hospital of Huabei Oilfield,Renqiu 062552,Hebei Province,China;Chu Hengqun,Second Hospital of Hebei Medical University,Shijiazhuang 050050,Hebei Province,China;Xu Ziting,Foreign Languages College of Sichuan University,Chengdu 61000,Sichuan Province,China  
Objective This paper discusses the important role of final quality methods in quality control of medical records.Methods As the standard of writing norms of medical records 1144 medical records are had examination and defects analysis.Results There are 214 defects medical records with 365 defect items,which defects rate is 18.7%.According to big items,small items and professional defects,it makes up a series of countermeasures.Conclusion The importance of final quality control of medical records is not to re-amend but to find out the basic reasons of medical records defects and to continually improve the medical records quality.
【CateGory Index】: R197.3
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