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The Municipal Hospital of Integrative Medicine Conducted the Inpatient Medical Records-writing Skills Competition
Date:December 19, 2017     Source:


  Medical records are the truthful records of patient diagnosis and treatment, which are also a true manifestation of clinician's clinical level and thinking process. Medical records are a testimony when any dispute between doctors and patients occurs, and are also the basic materials for scientific research. Medical records are also a miniature of the hospital and departmental quality management miniature.

   

  In order to promote the improvement of the quality of medical care in our hospital, we place emphasis on the medical record quality management as one of the important activities of "Medical Treatment Quality Improvement Year" in our hospital. On December 15, the "2017 Inpatient Medical Records-writing Skills Competition" was held at Yongding Road Hospital Area and the new site of North Hospital Area, under the joint organization of the hospital trade union, medical department and quality control department. The competition includes the preparation, publicity, medical records sampling and other stages, and participating doctors are divided into the surgery department group and internal medicine group, which are subject to the expert review respectively. This time, a total of 33 doctors took part in the competition, where the first copy of the medical records of discharged patients that each doctor wrote within the stipulated time was selected to truly reflect their writing skills of medical records.

   

  The review experts are mainly composed of the members of the ward department's medical record board and senior QC physicians. During the evaluation stage, the experts strictly implemented the review standards, commented on the records accurately, and exchanged the experience. Their dedication to in-depth discussions made the review atmosphere both serious and vigorous, which plays an important role in learning from each other's strengths. Each copy of medical records in the internal medical group is scored by the five experts scoring, while each copy in the surgical group is scored by the seven experts, where the highest scores are removed and then the average score of the remaining scorings is used as the final score.

   

  Finally, the 3 first-prize winners, 5 second-prize winners and 7 third-prize winners were selected in the internal medicine group; the 1 first-prize winner, 1 second-prize winner and 2 third-prize winners were chosen in the surgery group.

   

  The process of writing medical records reflects the implementation of many core medical systems, and the medical records quality control process embodies the self-correction and promotion of doctors. "Medical records can directly show the professional level of a doctor, so every doctor must attach significance to careful writing and enhance their writing quality."

  

   

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