目的提高病案质量,防范医疗纠纷。方法从2005年1月～2007年12月30,357份住院病案中随机抽取1500份病案进行调研。结果有40份病案检查检验报告单缺失,主要有病人原因、医生原因及辅助科医生原因,分别各占43.8%、37.5%、18.7%。采取相应对策,保证住院病案的完整性,使得检查检验报告单能够及时归档,提高医院甲级病案率。结论病案质量问题应该引起医院管理者、病案管理人员、医护人员的重视。 Objective To improve the quality of medical records and prevent medical disputes. Methods From January 2005 to December 2007, 30,357 inpatient medical records randomly selected 1500 cases for investigation. As a result, 40 medical examination report forms were missing, mainly including the cause of the patient, the reason for the doctor, and the reason for the assistant doctor, which accounted for 43.8%, 37.5%, and 18.7%, respectively. Take appropriate countermeasures to ensure the integrity of the hospital’s medical records, so that inspection and inspection reports can be archived in a timely manner and improve the hospital’s grade A disease rate. Conclusion The quality of medical records should cause hospital administrators, medical record managers, and medical staff to pay attention.