2002年1月到2003年12月共对24917份住院病案进行逐一评审,其中外科系统病案11577份,少于内科系统。但外科系统的乙级病案数是内科系统的6.8倍,病历缺陷率高出内科系统16%。本文仅从病案形成过程的角度分析影响外科系统病历质量的客观因素并提出相应的谬误防范建议。1影响外科系 From January 2002 to December 2003, a total of 24,917 hospital cases were reviewed one by one, of which 11,577 cases were surgical systems, which was less than the internal medicine system. However, the number of Class B cases in the surgical system was 6.8 times that of the internal medicine system, and the medical record defect rate was 16% higher than that of the internal medicine system. This article analyzes only the objective factors that affect the quality of the medical records of the surgical system from the perspective of the process of the formation of the medical record and proposes corresponding suggestions for the prevention of fallacies. 1 Influence Department of Surgery