Problems in Conversation Records of the Internal Medicine System and the Management Strategies

AbstractObjective. To analyze problems in medical conversation records and discuss management strategies. Method. Problems in 203 conversation records of five departments, generated from August 2013 to November 2013, were classified statistically. Results. A total of 39 conversation records were defective, accounting for 19.2% (39/203); of the 39 records, one problem occurred in 29 copies, accounting for 14.3% (29/203) and two or more problems occurred in ten copies, accounting for 4.9% (10/203). There were 54 problems in all the conversation records; each record had an average of 1.4 problems (54/39), and 69.2% (27/39) of the defective records were those of incomplete communication. Conclusion. Medical workers should carry out their duty of full medical disclosure, take medical conversations seriously and maintain written records, thereby improving the quality of medical records and reducing medical disputes.