Analysis of the First Page of 2,236 Medical Records with Writing Defects and Relevant Countermeasures

• DOI: 10.3109/23256176.2014.932073
• Publication Date: 2014-07-02T05:48:50Z
• Authors: Daqiao Zhu; Wenjun Zhang; Lijiang Yong; Shaoyong Huang
• Keywords: Medical record; Christian ministry

Objective. To analyze the writing defects in first page of medical records and propose improvement measures. Methods. The Quality Examination Score Scale First Page Medical Records was developed according to requirements Instructions for Filling Some Items on issued by former Ministry Health; from January February 2014 our hospital were randomly sampled; 2,236 obtained completeness each record analyzed. Results. proportion with no 49.41% (1,105/2,236); defect rate 50.58% (1,131/2,236); qualified 94.49% (2,113/2,236); unqualified 5.50% (123/2,236); there many problems such as incompleteness, mistakes, non-standard writing. Conclusion. problem poor quality severe. We should implement various measures strengthen training filling (2011 version) ensure that clinicians learn relevant knowledge; we auditing role coders code checking process, so improve accuracy authenticity information statistics.