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目的:分析病案首页基本信息存在的问题与对策。方法:抽查我院2011年7月至2012年8月10 000份住院病案,对首页的基本信息存在问题进行统计分析。结果:工作单位或地址、联系人电话、户口地址、职业、婚姻状况、身份证号码等为常见问题,通过三次核对,使最高项目错误比减低了68%。结论:病案首页的基本情况是鉴别患者身份的依据,及时、完整、准确的病案首页填写体现了医院的管理水平和医疗技术水平,提高病案首页的质量才可保证医疗信息资源得到充分的利用。
Objective: To analyze the problems and countermeasures of the basic information of the first page of medical records. Methods: A random sample of 10 000 inpatient medical records from July 2011 to August 2012 in our hospital were collected for statistical analysis of the existing basic information. Results: Frequently asked questions such as the employer or address, contact telephone number, account address, occupation, marital status and ID number were passed through three checks and the highest item error rate was reduced by 68%. Conclusion: The basic condition of the first page of the medical record is the basis for identifying the patient’s identity. The timely, complete and accurate first page of the medical record shows the management level of the hospital and the technical level of the medical technology. Only by improving the quality of the first page can the medical information resources be fully utilized.