目的 针对术前讨论制度执行情况常见问题，采取有效措施改进。方法 对 200 份手术病 历按照《病历书写规范》以及该院的《终末病历评分标准》进行质量检查和统计分析。结果 术前讨论记 录存在很多问题，与术前讨论存在形式化、医师书写病历不规范、上级医师对下级医师指导作用不强等有 关。结论 从严格执行术前讨论制度，保障手术安全；加强培训，规范病历书写；完善病历质量评分标准； 强化环节质控，确保内涵质量；落实终末质量检查，提高整体质量等进行改进，提高术前讨论质量，保障医 疗安全。

Objective To explore effective measures for target improvement，based on common questions in the implementation of preoperative discussion system. Methods Quality inspection and statistical analysis were performed in 200 cases of medical records. Results Many problems existed in the medical records，which were re⁃ lated with formalization of preoperative discussion，irregular writing of medical records and the weakened guidance role of senior doctors to junior doctors，etc. Conclusion The paper suggested to improve from five aspects to en⁃ hance the quality of preoperative discussion and to ensure medical safety，which include strict implementation of system for preoperative discussion to ensure surgery safety；enhancing training，standardization of medical re⁃ cords；strengthening quality control of process to ensure content quality；implementation of terminal quality inspec⁃ tion to improve the overall quality.