The promotion of day surgery has improved the procedure of the traditional inpatient surgery and put forward higher professional requirements for medical quality managers. Therefore, medical institutions need the matching norm of medical documents recording and management. The Medical Affairs Department and Day Surgery Center of West China Hospital of Sichuan University keep exploring and practicing new norm which should be conform with the diagnosis and treatment characteristics of the daytime operation mode to insure medical treatment quality and simplify the writing work of medical documents. This new recording norm of West China Hospital of Sichuan University for day surgery should not only meet the basic requirement of the medical record writing, but also stipulate the content detail and add more assessment rules for records grading. Moreover, the new norm could actively explore the management mode of medical record quality for day surgery. For example, by arranging the medical record quality monitors and arousing the working enthusiasm of clinical department and day surgery center through the (hospital and clinical departments) two-level management mode, the medical record writing process could be normalized, and the quality of medical records could also be well guaranteed.
Citation： SHUAI Bingxing, LI Zhichao, ZHANG Xiaorong, WANG Yong, MA Hongsheng, DAI Yan, CHEN Min, LI Dajiang. Exploration and practice of the norm of medical records for day surgery in West China Hospital of Sichuan University. West China Medical Journal, 2019, 34(2): 145-149. doi: 10.7507/1002-0179.201901115 Copy