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目的探讨提高出院病案首页书写质量的有效途径。方法总结提高病案首页书写质量的经验,建立病案首页填写的四级管理制度。结果2007年7月～2008年4月各月出院病案的首页填写缺陷率逐月下降。结论减少病案首页书写缺陷,提高病案首页书写质量是一项系统工程,需要全体医务人员的共同努力,同时对病案首页书写的监控工作要坚持长抓不懈,才能提高病案首页书写质量。
Objective To explore an effective way to improve the writing quality of the first page of discharged medical records. Methods Summarize the experience of improving the writing quality of the first page of the medical record and establish the four-level management system filled in the first page of the medical record. Results From July 2007 to April 2008, the first page of the discharge records for each month was decreased month by month. Conclusions Reduce the writing defects and improve the medical record Home writing quality is a systematic project that requires the joint efforts of all medical staff. At the same time, we must persevere in monitoring the writing on the first page of medical records in order to improve the writing quality of the first page of medical records.