Objective To analyze the results of the quality inspection of the content of terminal medical records in a tertia-ry hospital,summarize the causes of common problems,and propose corrective measures to provide a basis for the efficient imple-mentation of medical record quality management work.Methods Based on Zhejiang Province medical record quality scoring crite-ria,a medical record quality inspection scoring form was developed for the hospital.A total of 7,140 terminal medical records dis-charged from the hospital between January 1,2023,and December 31,2023,were randomly selected for content quality inspection.The discharge rate and major defect occurrence rate of medical records before and after quality improvement were compared.Results After the implementation of corrective measures,the overall qualification rate of discharged medical records increased from 84.76%to 91.38%,and the rate of individual vetoed medical records decreased from 6.07%to 2.32%,with statistically signifi-cant differences(P<0.05).The frequency of major defect issues and major individual veto issues in discharged medical records decreased after the improvement,with statistically significant differences in the two groups(P<0.05).The frequencies of issues regarding the lack of a 72-hour conversation record and the lack of the first postoperative course did not show significant changes before and after the improvement,with no statistically significant differences(P>0.05).After the improvement,the number of medical teams with a twelve-point deduction score≥6 decreased from 28 to 8,with statistically significant differences(P<0.05).Conclusion Many factors can affect the quality of medical record writing.By implementing a series of corrective meas-ures such as strengthening medical record writing training,enhancing the four-level quality monitoring system of medical record management,improving the reward and punishment system,establishing a convenient and efficient communication platform,and strengthening quality management in various stages,the quality of medical record writing can be effectively improved.

Objective To utilize AI technology to achieve quality control of all medical records,further standardize the medical record writing process,and address the shortcomings of the manual quality control model,such as the inability to cover all medical records.Methods Based on the paperless electronic medical record system,an electronic medical record quality control system based on AI technology was constructed.The system achieves automatic monitoring,reminders,and feedback functions for all electronic medical records by running quality control rules.Results The AI quality control system has achieved real-time quality control of 100％of electronic medical records,significantly improving the timeliness and completeness of medi-cal record writing.Conclusion The medical record quality control system based on AI technology can effectively enhance the ef-ficiency of hospital medical record quality control,significantly improve the quality of electronic medical record writing,and solve the shortcomings of manual quality control.