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目的针对病案首页基本信息填写出现的问题,建立病案首页更正单,以校正病案首页基本信息出现的错误,提高病案首页质量。方法由临床科室填写首页更正单,需填写更正理由及更正内容,并由相关人员签字,然后病案科复印盖章,将复印件交给患者。结果采用病案首页更正单,可以确保患者信息准确完整。结论病案首页更正单,对报销医药费、开具医疗证明等具有重要的作用。同时在临床、教学、科研和医院管理等方面也具有积极的作用。
Objective To fill in the basic information of the first page of the medical record and to establish the first page of the medical record correction list so as to correct the errors in the basic information of the first page of the medical record and improve the quality of the first page of the medical record. Methods Fill out the home page correction form by the clinical departments, fill in the corrective reasons and corrections, sign the relevant personnel, copy and seal the case record, and hand over the copy to the patient. The results using the first page of medical records to correct a single, to ensure accurate and complete patient information. Conclusion The first page of the medical record is correct, which plays an important role in reimbursement of medical expenses and issuance of medical certificates. At the same time in clinical, teaching, research and hospital management also has a positive effect.