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病案首页是病案中信息最集中、最重要、最核心的部分,无论统计填表、医院管理、病例检索都离不开病案首页提供的信息。病案首页的重要功能往往引不起临床医生的重视,所以漏填、错填的现象较为普遍,甚至影响统计工作的准确性,病案填写的质量管理显的尤为重要。为进一步加强病案首页管理,我们对影响病案首页的原因进行了调查分析,制定了一系列管理措施,加强每个环节的管理,经过几年的应用,不合格病案首页大幅度的减少,起到了显著的效果。
The first page of the medical records is the most concentrated, the most important and the core part of the information in the medical records. No matter whether the statistics are filled in, hospital management or case retrieval are inseparable from the information provided on the first page of medical records. The important functions of medical record home page often can not afford the attention of clinicians, so the phenomenon of missing fill and wrong fill is more common, even affecting the accuracy of statistical work. Quality management of medical record filling is especially important. In order to further strengthen the front page management of medical records, we conducted a survey and analysis on the causes affecting the front page of medical records, formulated a series of management measures to strengthen the management of each link, and after several years of application, the number of unqualified medical records dropped drastically, Significant effect.