Analysis and Countermeasures for Writing Quality of Manuals of Medical Records in Outpatient and Emergency in Community Health Service Institutions

AbstractObjective. To formulate countermeasures by analyzing the defects in manuals of medical records in outpatient and emergency, in order to improve the quality of medical records. Method. The check and statistical analysis were performed according to Methods for the Administration of Beijing Community Health Assessment (Trial). Result. A total of 528 manuals of medical records in outpatient and emergency were checked at random, and defects of 119 medical records were identified. Conclusion. Methods for strengthening the education and training of general practitioners, establishing a sound performance appraisal system, implementing an accountability system, performing inspection and assessment regularly, enhancing the summary and communication, and performing continuous improvement, etc. should be adopted to improve the writing quality of manuals of medical records in outpatient and emergency by a variety of measures.