目的找出住院病案缺陷的常见原因及解决办法。方法对2002年1月～2004年4月出院归档并进行终末质控的15244份病案作回顾性分析。结果15244份病案中首页缺陷者共436,份,占2.87%;其它缺陷病案返修数共892份,占5.85%。结论加强医师的法制观念,强化基本功训练,坚持三级质控是确保病案质量的关键。 Objective To find out the common causes and solutions to the defects of inpatient medical records. Methods A retrospective analysis of 15,244 medical records that were discharged from hospital from January 2002 to April 2004 was performed. Results Of the 15244 cases, the home defect was 436, accounting for 2.87%; the number of other defect cases was 892, accounting for 5.85%. Conclusion To strengthen the doctor’s concept of legal system, strengthen basic skills training, and adhere to the three levels of quality control is the key to ensuring the quality of medical records.