为提高病案首页和统计数字质量,确保首页录入的准确,我院在病案首页录入工作中实行了“三查七对”即录入前(回收时)、录入时、录入后(核查员)检查;认真核对姓名和性别、出生年月和年龄、工作单位和户口地址、住院和出院日期(住院天数)、入院和出院诊断、出院情况及费用。通过这项措施的实施增强了病案管理人员的责任心,提高了病案人员的业务水平;病案首页的质量提高,有力地支持了病历质量管理;增加了系统分析的可信度,拓宽了统计分析的范畴。 To improve the quality of the first page of medical records and the quality of statistics, to ensure the accuracy of the first page entry, our hospital implemented the “three check and seven pairs” in the first page of the medical record before entry (during the collection) Carefully check name and gender, date of birth and age, address of work unit and household, dates of hospitalization and discharge (length of stay), admission and discharge diagnoses, discharges and costs. The implementation of this measure enhances the sense of responsibility of medical record administrators and improves the professional level of medical record staffs. The quality improvement of medical record homepage strongly supports the medical records quality management, increases the credibility of systematic analysis and broadens the statistical analysis Category.