病案首页信息不仅是医院开展医疗统计工作的基础,也是医院进行科学管理的客观依据。病案首页信息填写常见错误有主要诊断、确诊日期、诊断符合情况、抢救次数和成功次数填写错误。这些病案首页信息填写错误将会对疾病分类统计分析、病种管理、三日确诊率、危重病人抢救成功率等造成不同的影响。病案首页信息与医疗质量管理密不可分,建议:(1)将国际疾病分类列入医学生的基础教育教材;(2)将病案首页填写作为新进人员、进修生岗前培训的必备内容,并纳入等级医院评审标准;(3)在医疗质量管理过程中不断改进、提高病案首页的填写质量;(4)加强编码员培训学习、考核持证上岗,(5)将病案首页填写说明中有关“临床与病理符合”的内容重新定义。 The first page of medical records is not only the basis of medical statistics carried out by hospitals, but also the objective basis for scientific management of hospitals. Medical records Home information fill in common mistakes There are major diagnosis, diagnosis date, diagnosis of the situation, the number of rescues and the number of successes. Fill in the wrong information on the first page of these medical records will have different effects on the statistical analysis of disease categories, the management of disease types, the three-day diagnosis rate and the successful rescue rate of critically ill patients. Medical information and medical quality management are inseparable, it is recommended: (1) the international classification of diseases classified as medical students basic education textbooks; (2) the first page of medical records as new recruits, pre-service training prerequisites, And included in the level of hospital accreditation standards; (3) continuous improvement in the medical quality management process to improve the quality of the first page of the medical record; (4) to strengthen the training of coders learning, examination certificate of employment, (5) “Clinical and pathological consistent ” content redefined.