目的了解门诊病案书写质量状况,提高医疗文件质量。方法对我院2003年7月至2003年10月门诊就诊患者的病案进行随机抽查,寻找门诊病案质量中的不足之处,并提出对策。结果门诊病案缺陷8类,合格率92.07%。结论分析门诊病案质量缺陷,提出对策,有利于提高病历书写质量。 Objective To understand the writing quality of outpatient medical records and improve the quality of medical documents. [Methods] Random sampling of medical records of outpatients in our hospital from July 2003 to October 2003 was conducted to find out the deficiencies in the quality of outpatient medical records and put forward countermeasures. Results There were 8 types of outpatient medical defects, and the qualified rate was 92.07%. [Conclusion] Analyzing the quality defects of outpatient medical records and proposing countermeasures will help improve the writing quality of medical records.