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目的通过分析病案首页存在问题,进一步提高病案信息质量。方法按2001年卫生部颁发的病案首页填写标准,对某院病案首页信息填写质控、检查分析。结果检查3864份病案首页,323份存在缺陷,归纳出影响病案首页填写质量的因素。结论通过医院管理部门、病案管理人员和临床医师的共同努力,确保病案首页的准确性,才能保证医疗信息的质量。
Objective To further improve the quality of medical record information by analyzing the existing problems on the front page of medical record. Methods According to the first page of the medical record issued by the Ministry of Health in 2001, the first page of the medical record of a hospital was filled in with quality control and inspection analysis. Results 3864 copies of the first page of medical records, 323 defects, summed up the impact of the first page of medical record quality factors. Conclusion Through the joint efforts of the hospital management department, case management staff and clinicians to ensure the accuracy of the first page of medical records, the quality of medical information can be guaranteed.