目的分析手术科室运行病历书写存在问题,提高病历质量。方法根据陕西省卫生厅编写的《病历书写规范》标准,随机抽取1460份手术科室运行病历,进行检查,并对存在问题统计分析。结果1460份病历中,缺陷病历235份,占16.1%。结论加强手术科室运行病历书写的质控,保证病历的及时性、真实性和完整性,是提高科室医疗质量和防范医疗纠纷和事故发生的重要举措。 Objective To analyze the problems existing in the operation records writing in surgical department and improve the quality of medical record. Methods According to the “Medical Record Writing Standard” standard prepared by Shaanxi Provincial Department of Health, 1460 surgical departments were randomly selected to run medical records and examined. Statistical analysis of existing problems was made. Results 1460 medical records, defect medical records 235, accounting for 16.1%. Conclusion It is an important measure to improve the medical quality of departments and prevent medical disputes and accidents by strengthening the quality control of medical record writing in operating departments and ensuring the timeliness, authenticity and completeness of medical records.