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

Abstract

AbstractObjective. To analyze the writing defects in the first page of medical records and propose improvement measures. Methods. The Quality Examination Score Scale of First Page of Medical Records was developed according to the requirements of the Instructions for Filling Some Items on the First Page of Medical Records issued by the former Ministry of Health; the medical records from January to February 2014 of our hospital were randomly sampled; 2,236 records were obtained and the completeness of the first page of each record was analyzed. Results. The proportion of the medical records with no defects in the first page was 49.41% (1,105/2,236); the defect rate was 50.58% (1,131/2,236); the qualified rate of the first page of the medical records was 94.49% (2,113/2,236); and the unqualified rate was 5.50% (123/2,236); there were many problems in the first page of medical records such as incompleteness, mistakes, and non-standard writing. Conclusion. The problem of poor quality in the first page of medic...