Purpose: By statistically analyzing the defects of unqualiifed hospitalized medical records, the paper aims to discuss the countermeasures for improvement with a view to promote the medical record quality. Method: The Scoring Form for Hospitalized Medical Record Quality Inspection formulated by reference to the Writing Norms and Administrative Regulations of the Guangxi Zhuang Autonomous Region on the Medical Record of Medical Institutions issued by the Health and Family Planning Commission of the Region is taken as the scoring standard, and 220 unqualiifed hospitalized medical records are collected for statistical analysis on defects; these records were sampled at random by the hospital's Medical Record Management Commission from the clinical departments on a monthly basis from 2012 to 2014. Result: Among the 220 unqualiifed medical records, there are 156 in which the single rejection item is not finished on time, amounting to 70.9%; 146 in which the medical history recorded during admission to hospital is incomplete, occupying 66.4%; 123 carrying contradictory contents (i.e., copied medical records), taking up 55.9%; 119 in which the record of daily disease course/superior physician ward-round is not ifnished in time, occupying 54.1%; 83 not recording the requested consultation, accounting for 37.7%; 78 without the analysis on special examination and medication course, amounting to 35.5%; and 66 without the analysis on abnormal examination result and disease course, taking up 30%. Conclusion: The quality management over medical record should be strengthened. The medical institution should improve the quality management system for both ordinary and electronic medical records, enhance the training of physicians on medical record writing, give full play to the initiative of clinical departments' directors and special quality controllers, intensify reward and punishment, and meanwhile introduce in strongly practical management tools to control the special medical record quality, in order to promote the continuous improvement of medical record quality and clinical medical quality.%目的：通过对不合格住院病历进行缺陷统计分析，讨论研究改进策略，从而提高病历质量。方法参照广西卫生计生委下发的《广西壮族在自治区医疗机构病历书写规范与管理规定》制定该院《住院病历质量检查评分表》以作为评分标准，并收集该院病案管理委员会2012年至2014年每月在该院临床科室随机抽查出的220份不合格住院病历进行缺陷统计分析。结果220份不合格病历中，单项否决项目未能按时完成有156份，占70.9%，入院录病史书写不完善的有146份，占66.4%，病历中记录内容相互矛盾即拷贝病历有123份，占55.9%，日常病程/上级医师查房记录完成不及时的有119份，占54.1%；请会诊无记录的病历有83份，占37.7%；特殊检查和用药病程无分析的有78份，占35.5%；异常检查结果病程无分析的有66份，占30.0%。结论应加强病历质量管理，医疗机构要完善病历质量管理体系及电子病历质量管理系统，加强医师病历书写方面的规范化培训，充分发挥临床科室科主任及专项质控员的能动性作用，同时加大奖罚力度，引进实用性强的管理工具开展专项病历质量管理，以促进病历质量和临床医疗质量的持续改进。
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