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目的保证病案首页的及时性、准确性和完整性。方法通过运用2010版军队医院数据核查软件和核查条件,对新版病案首页的填写重新核查,从中发现问题、指出正确填写标准。结果新版病案首页增加了病人基本信息内容,完善并规范了某些专业术语,增加了医师身份确认等项目。新版病案首页使用中在基本信息部分和病人医疗信息部分尚存在若干问题。结论加强工作人员培训、质控员的审核是提高病案首页填写质量的关键。
Purpose To ensure the timeliness, accuracy and completeness of the first page of the medical record. Methods Through the use of 2010 version of the military hospital data verification software and verification conditions, the first page of the new medical records to re-check fill out the problems found that the correct fill in the standard. Results The first page of the new medical records increased the basic information of the patients, improved and standardized certain terminology, and increased the physician identification and other items. New version of the first page of medical records in the basic information section and the patient medical information section there are still some problems. Conclusion Strengthening staff training and quality control staff examination is the key to improving the quality of the first page of medical record.