Probe of the New Pattern of Mutual Evaluation of Medical Records Among Hospitals

Abstract

The quality of medical records is the focus of medical quality management. It is critical to improve the quality of medical records and strengthen the quality management of medical records. Since the system of mutual evaluation of medical records has been implemented, our hospital and other 3A hospitals within the province, have learned strengths from each other and overcome our weaknesses, taken effective quality control measures, and greatly improved the integrity of information in the first pages of medical records, the details of discharge records and discharge orders, copies of the course of diseases, the connotation of the ward rounds made by senior physicians, failure in modifying medical records, and so on. As a result, the quality of medical records has improved comprehensively. Meanwhile, mutual evaluation has improved the quality controllers’ working skills in the quality control of medical records and fully aroused the clinician's enthusiasm for the self-control of the quality of medical records and the writing of high quality medical records. The mutual evaluation of medical records, as a new pattern in the quality control of medical records, is an excellent addition to the intrahospital measures to control the quality of medical records. We can continuously improve the mutual evaluation pattern by making continuous progress in the mutual evaluation procedure.

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