目的总结我院2001年~2004年病案首页存在的问题,从而为我院制定病案管理具体实施细则提供可行性依据。结果2856份病案首页填写项目不全的有312份中占10.9%;结论目前基层医院病案首页的填写还存在着较多的问题,不能完全体现病历的真实性和可靠性。因此,基层医院应将对病案首页检查考核,纳入质量标准化、程序化、规范化管理。 Objective To summarize the problems existing on the front page of the medical records in our hospital from 2001 to 2004, and to provide a feasibility basis for the formulation of detailed implementation rules for medical record management in our hospital. [Results] Of the 2856 medical records on the front page, 312 of the 312 cases were incomplete. 10.9% of the total number of cases were incomplete. Conclusion At present, there are still many problems in the filling of the first-level medical records of primary hospitals, which cannot fully reflect the authenticity and reliability of medical records. Therefore, grass-roots hospitals should check and assess the top of the medical record and include quality standardization, procedural, and standardized management.