随着社会的不断进步,病案的价值日益提高。病案首页中主要诊断的正确选择将直接影响到病案质量及卫生统计报表的数据。医疗保险在我国的广泛实施,疾病的分类编码以及正确选择疾病的主要诊断,更是关系着医院、医保单位、病人的合法权益。加强临床医师、病案管理人员对疾病分类的认识提高病案质量,病案信息的作用和社会价值才能充分得到体现。 With the continuous progress of society, the value of medical records has been increasing. The correct choice of the main diagnosis in the first page of the case will directly affect the data on the case quality and health statistics. The widespread implementation of medical insurance in China, the classification and coding of diseases, and the main diagnosis of correct choice of diseases are related to the legitimate rights and interests of hospitals, medical insurance units, and patients. Strengthen the understanding of disease classification by clinicians and medical record management personnel to improve the quality of medical records, and the role and social value of medical record information can be fully reflected.