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目的探讨如何运用信息技术提高病案首页的填写质量。方法分析医院现有信息录入过程中,病案首页填写质量存在的诸多原因和不利影响。结果医院利用信息技术力求实现数据自动生成,控制了数据录入过程中的偏差,弥补了病案首页填写标准掌握不准的质量缺陷,提高了病案首页填写的准确性。结论运用信息技术加强病案首页管理,减少录入的随意性,提高了病案首页涉及专业性强的项目填写质量,更好的发挥病案首页的信息价值。
Objective To explore how to use information technology to improve the quality of the first page of medical records. Methods Analysis of the existing hospital information input process, the first page of the medical record quality exists many reasons and adverse effects. Results The hospital made use of information technology to realize the automatic data generation and control the deviation in the process of data entry, which made up for the quality defects that the standard of the first page of the medical record was not approved and improved the accuracy of the first page of the medical record. Conclusion The use of information technology to strengthen the front page management of medical records to reduce the randomness of entry, improve the quality of the first page of the case involving professional expertise to fill in the quality of the information on the first page of the case.