Objective Discussion on standardizing the writing of medical records, timing summarizing problems in the writing of clinical cases, put forward rectification measures, to improve the quality of medical records, reduce vulnerability, the prevention of medical disputes.Methods Medical records were checked randomly, Assessment, For the existing problems put forward rectification measures.Result A random sampling survey, The medical term clinical records of non-standard, the handwriting was difficult to identify, typos, Implementation is not complete and auxiliary examination results and lack of timely rectification, In order to improve the quality of medical records, medical dispute. Conclusion Medical record writing quality management is the important content of hospital quality management, Specification of the medical record writing can improve the quality of medical record management, The medical record management standardization, the informationization and the legalization, The implem