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目的对我院2010年29,183份例手术病案首页诊断填写审核,以便提高病案首页诊断的完整性。方法对3581例漏填诊断的病案进行统计、分析。结果发现高血压等内科疾病诊断漏填比较严重。结论针对病案首页漏填的问题采取相应措施,减少以后此类问题的出现。
Objective To check the first page of 29,183 surgical cases in our hospital in 2010 in order to improve the integrity of the first page of medical records. Methods A total of 3581 cases of diagnosis of missed diagnosis and statistics were analyzed. The results showed that the diagnosis of hypertension and other medical diseases more serious leakage. Conclusions Take appropriate measures to solve the problem of homepage leakage in case homepage, and reduce the emergence of such problems in the future.