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病案首页是住院病案的重要组成部分,是病人综合信息的概括和缩影,是医院统计、医疗管理和临床医学研究的重要原始数据来源。主要诊断选择不当影响病案疾病分类检索和病案临床利用。通过对病案录入系统进行改进、提高临床医生主要诊断选择水平、加强病案质控等系列措施,使病案首页资料的准确性和病案质量不断提高。
The front page of medical records is an important part of inpatient medical records. It is a summary and microcosm of patient comprehensive information and is an important source of data for hospital statistics, medical management and clinical medical research. The main diagnostic options improperly affect the medical record classification and medical record clinical use. Through the improvement of the medical record input system, improving the clinician’s main diagnostic options and strengthening the quality control of medical records, a series of measures are taken to improve the accuracy of the medical records and the quality of medical records.