Abstract
AbstractObjectives. Analysis of the defects in our hospital's computer records, to explore an effective method to improve the computer to maintain the quality of medical records. Method. Using the publication issued by the Ministry of Health on “medical record writing basic norms” as the standard, to make statistical analysis of computerized medical records after 9 months of medical record quality inspection. Of the 10413 computerized terminal medical records, a total of 2718 samples of defects in medical record writing were detected, relating to over-reliance on the template. The framework of the medical record copies was also one of the main problems. Conclusions. There should be standardized management of computers used to enter medical records, strengthen the communication between departments, improve physicians’ ideological understanding, and strengthen basic training, maintain strict reward and punishment system aspects to improve the quality of medical records.
Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
