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病案首页是一份压缩了的住院病案,是病案信息的综合反映,医疗统计、医疗管理和临床医学研究的原始数据来源,是医疗保险赔付、医疗纠纷处理的重要依据[1-3]。为了提高病案首页的终末质量和医疗数据统计的及时性。笔者研发了病案首页环节质量控制系统,旨在加强病案首页书写内容和
The first page of the medical record is a compressed inpatient medical record which is the comprehensive reflection of the medical record information. The original data sources of the medical statistics, medical management and clinical medical research are the important basis for the treatment of medical insurance claims and medical disputes [1-3]. In order to improve the final quality of the medical records and the timely medical statistics. I developed the first page of the medical records quality control system designed to strengthen the first page of medical records and content