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卫生部统一颁发的病案道页是病案中信息最中、最重要、最核心部分。统计报表,医院管理、病例检索都离不开首页提供的信息。尤其在病案管理微机化的今天,首页已成为医疗、教学、科研的重要资料之一,成为国际间医学交流的桥梁。因此,首页填写的准确性、完整性显得十分重要,现将我院检查450份病案首页结果分析如下。
The road map of the disease issued by the Ministry of Health is the most important, most important, and most central part of the information in the medical record. Statistical reports, hospital management, and case searches are inseparable from the information provided on the homepage. Especially in today’s computerized medical record management, the homepage has become one of the important materials for medical treatment, teaching, and scientific research, and has become a bridge for international medical exchanges. Therefore, the accuracy and completeness of the homepage are very important. We will now analyze the results of the 450 home medical records in our hospital as follows.