Objective To strengthen the management of medical records quality and improve medical quality. Methods We determined the content of real-time monitoring medical records in ward and made timely adjustment, developed standards for assessing medical records, and linked medical records quality to the comprehensive evaluation of medical quality of departments. Result The quality of perieperative medical- records and roanagement of patients＇ medical records with chronic disease should be paid attention.Conclusion To carry out the real-time mornitoring of medical documentation so that the quality control methods can be adjusted for problems in each stage in ward.
Chinese Medical Record
medical records in ward