In order to improve the quality of medical records written by interns in hematology department

we evaluated and analyzed 100 medical records written by the interns. The main reasons that affect the quality of medical record written by interns are the writing defects that are history of present illness

past history

personal history

the record of the clinical operation

blood transfusion and chemotherapy. There are other reasons for affecting the quality of medical records

such as the writing of medical records were not enough pay attention to in the clinical practice

the relative lag of teaching management

the specificity of hematological diseases

and so on. So the corresponding countermeasures have been suggested: firstly

the teaching management must be strengthened

and the synthetic quality of teachers must be improved. Secondly

it is necessary to pre service training of writing medical records for interns and to cultivate the ability of interrogation

doctor-patient communication. Finally

we can use the typical medical records of hematology combined with medical records discussion method and other ways

so as to enhance the medical record writing skills of medical interns

and constantly improve the quality of medical records writing teaching.