目的规范病历书写,促进医院管理制度的落实,使医疗质量和医疗安全不断提升。方法根据医院终末病案质量评估标准,对2006年~2007年的出院病案进行质量监控。结果两年间缺陷病案占出院病案总数的2.65%,2006年甲级病案率96.36%,2007年甲级病案率98.22%。结论强化病案重要性认识,持续改进工作方法,有利于病案质量的提高。 Objectives To standardize the writing of medical records and promote the implementation of hospital management systems so that the quality of medical care and medical safety will continue to increase. Methods According to the quality evaluation standard of the hospital terminal medical record, the quality monitoring of the discharged medical record from 2006 to 2007 was carried out. Results In the two years, the deficit cases accounted for 2.65% of the total number of discharged cases. In 2006, the rate of Grade A cases was 96.36%. In 2007, the rate of Grade A cases was 98.22%. Conclusion The importance of strengthening the medical record and continuously improving the working methods are conducive to improving the quality of medical records.