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目的探讨病案首页信息标准化建设。方法根据现行病案首页信息统计分析,对有关标准不一致处提出建议。结果对病案首页信息逐项提出要求及有关标准。结论病案首页信息的各项目必须统一要求、统一标准,以便医院间病案信息交流与资源共享。
Objective To explore the standardized construction of the first page of medical records. Methods Based on the statistical analysis of the first page of the medical records, suggestions about the inconsistent standards were put forward. Results of the first page of information on medical records put forward requirements and related standards. Conclusion The items on the home page of the medical record must be uniformly standardized and standardized to facilitate the exchange of medical record information and resource sharing among the hospitals.