目的规范出院记录书写和确保出院记录质量。方法按照安徽省卫生厅《病历书写基本规范》对出院记录的要求,自设调查表,将缺陷分为12项指标,对5684份出院记录常见缺陷调查。结果存在缺陷的记录2554份,缺陷率45%,缺失项目现象严重。结论出院记录质量亟待提高,需解决深层次原因。 Objective To regulate the discharge record writing and to ensure the quality of discharge records. Methods According to the requirements of discharge record of “Basic Medical Records Writing Criteria” issued by Anhui Provincial Department of Health, a questionnaire was set up to divide the defects into 12 indicators and investigate the common defects of 5684 discharge records. The results of the defect records 2554, 45% defect rate, the phenomenon of missing items serious. Conclusion The quality of discharge records needs to be improved urgently, and the underlying causes need to be resolved.