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病案首页和病案记录及时签字,确保病案内容资料完整、正确、规范,才能及时归档,容易查找,不易丢失病案。经过各级医师审签确认后的病案资料,方可为医疗、科研、教学、社会保险、法律部门、医院管理、经济方面提供内容正确的病案信息。通过人性化管理和为签字医师提供满意的服务,可以督促各科主任和临床医师及时完成病案首页审核签字工作,以达到加强病案首页签字的监控管理。
Medical records and record the first page of medical records in a timely manner to ensure that the contents of the medical records integrity, correct, standardized, timely archiving, easy to find, not easy to lose the case. After all levels of medical examination and verification of medical record data, medical and scientific research, teaching, social insurance, legal department, hospital management, and economic aspects of medical records to provide the right information. Through humanized management and providing satisfactory services to signatories physicians, supervisors and clinicians of all disciplines can be urged to timely complete the audit and signature on the home page of medical records so as to strengthen the supervision and management of signature signatures of medical records.