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《Chinese Medical Record》 2018-06
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Defect Analysis of Medical Records Written by Endocrinology Medical Interns

Cao Xuexia;Sun Li'na;Ma Yahui;Mu Zhijing;Department of Endocrinology,Xuanwu Hospital of Capital Medical University;  
Objective This paper aims at analyzing defects of writing medical records(MRs)and improving the quality of writing MRs.Methods 182 MRs(the original records:91,and the modified ones:91),written by the interns from September 2016 to July 2017 at a certain Hospital,were collected and analyzed via tools of descriptive statistics and chi-square test.Factors affecting the writing MRs in 91 questionnaires filled out by the interns were also analyzed through logistic regression technique.Results Finding showed that the highest defect percentage(65.9%)is allocated to history of present illness(HPI)and the lowest percentage(9.9%)is auxiliary examination.The writing quality of items except three ones,-other history of illness,diagnostic analysis,and initial course taking(their p-values are more than 0.05)-,were improved significantly.Especially,non-defect percentage of HPI increases from 34.1% to 70.3%.The two factors may affect the quality of writing HPI were"whether the students actively learn the knowledge of writing MR"and"satisfaction of evaluation on the quality of writing MR".Conclusion Maximum probability of defects is writing HPI.Improving quality of writing MR needs increase in extensive clinical experience.Students are not aware of the importance of writing MR,and their learning initiative should be improved.Additionally,practice evaluation on writing MR needs to be enhanced.
【CateGory Index】: G642;R-4
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