目的分析病案首页常见质量缺陷,促进住院病案首页书写规范化。方法对1247份病案首页书写缺陷进行统计分析。结果常见填写缺陷有转归不准确、损伤中毒外部原因过于笼统、出院诊断顺序混乱等。结论根据病案首页书写的问题提出改进对策:全程质控为主,终末质控为辅;加强医师岗前培训及继续教育;提高病案首页录入人员的业务素质。 Objective To analyze the common quality defects on the first page of the medical record and to promote the standardization of the first page of inpatient medical records. Methods Statistical analysis was performed on the writing defects of 1247 medical records on the front page. Results There were inaccurate outcomes in common defects, too general external causes of traumatic poisoning, and disordered discharge order. Conclusion According to the problem of writing on the front page of the medical record, we put forward improvement countermeasures: quality control is the main method, and final quality control is the supplement; strengthen pre-service training and continuing education of doctors; improve the quality of the personnel entered on the front page of medical records.