Survey of the standardization of medical records writing by physicians
10.3760/cma.j.issn.1000-6672.2011.01.005
- VernacularTitle:住院医师病历书写规范程度调查
- Author:
Yanmin CHEN
;
Yan LIU
;
Yamin LIU
- Publication Type:Journal Article
- Keywords:
Residents;
Medical records;
Recognition rate;
Grade evaluation
- From:
Chinese Journal of Hospital Administration
2011;27(1):12-15
- CountryChina
- Language:Chinese
-
Abstract:
Objective To study the standardization of medical records writing by residents in hospitals. Methods With both quantitative and qualitative analysis, medical records made by residents were sampled in groups to study their standardization. Results Recognition rate of such medical records was 82. 55%, and the excellence rate was 24. 50% in the grade evaluation. For senior residents, their rate of writing excellence falls below those of junior ones; whether the evaluators have medical background bears no significant difference for grade evaluation of medical records writing, yet a significant difference was found with the recognition rate. Conclusion Writing of medical records by residents is found with incompliance now and then, and the recognition rate ought to be improved.
