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病案首页是病案的核心部分,根据《住院病案首页填写要求》,对病案首页质量进行跟踪分析,发现病案首页错误和缺陷多是由录入人员责任心不强、医师不熟悉首页填写要求、个别医师诊断随意性较大等原因所致。因此,医务处加强管理监督,信息科及时跟踪问效,录入人员增强责任心,临床医师不断学习提高,各部门通力合作,才能有效提高病案首页质量。
The first page of the medical record is the core part of the medical record. According to the “First page of the medical record”, the quality of the first page of the medical record is traced and analyzed. The first page of the medical record is found to be faulty and deficient. The physicians are not familiar with the first page, Diagnostic randomness and other reasons. Therefore, the Medical Department to strengthen management and supervision, information and timely tracking of effectiveness, entry staff to enhance accountability, clinicians continue to learn to improve, all departments cooperate in order to effectively improve the quality of the first page of the medical record.