Measures to Improve the Existing Problems in the Medical Records of the Neurosurgery Department

AbstractSome problems such as one-sidedness in parsing problems, lack of connotation, time limit error, missing items in content, and copy error commonly occur during the writing of medical records by neurosurgeons. We need to strengthen “three bases” during the training of resident physicians, standardize medical record writing, highlight the regulatory functions of attending physicians, strengthen the “three-level” supervision of medical record quality, and implement a system to continuously improve the quality of medical records, along with a series of measures to standardize the diagnosis and treatment behaviors, in order to improve the medical record writing quality, and to enhance the connotation of medical records.