Improve the medical record quality management organizational system at the hospital and department levels

Improve medical staff's awareness of the importance of medical record writing, strengthen the standardization awareness of medical record writing, cultivate medical staff's clinical thinking ability, and improve the quality and efficiency of medical record writing.

Promote communication and cooperation among medical staff to jointly improve clinical diagnosis and treatment.

Implement clinical diagnosis and treatment management requirements, cultivate clinicians’ diagnosis and treatment thinking and basic medical record writing skills, become familiar with medical record quality standards, and be able to apply them skillfully in the actual writing and quality control process

Build a learning and exchange platform for medical staff and promote the inheritance of clinical experience

Enhance the scientific research value of medical records

The Medical Department is responsible for training on medical management policies, systems and medical record management requirements.

The medical record guidance consultant conducts training on the basic requirements for medical record connotation and recording key points based on policies, systems, management requirements, and specialty diagnosis and treatment characteristics.

The directors of each department implement policies, systems, and medical record recording and quality control requirements for the diagnosis and treatment process.

Physicians at all levels implement the core systems of each medical group and relevant requirements for medical record writing

Medical record quality controllers implement the quality control of medical records in each department

Expert lecture

Medical records discussion meeting

Excellent medical records (cases) sharing session

Expert guidance and review sessions

Summary feedback meeting

Master the basic rules for writing medical records

Familiar with medical record quality evaluation standards

Can guide "three students" to write medical records and check on time

Medical record quality controllers master quality control standards and implement quality control responsibilities

Able to complete the medical records of the patients in charge according to the basic standards for medical record writing and core system requirements.