论文部分内容阅读
目的寻找提高病案首页质量的方法及监控措施,使病案信息能有效利用。方法根据《住院病案首页填写的要求》,对病案首页质量管理进行分析。结果病案首页错误多由录入员责任心不强、医师对病历书写规范不熟悉、科室质控流于形式、病案管理岗位人员缺乏所致。加强维汉双语宣传、强化医师培训、把好信息录入关、解决病案管理人员短缺、提升病案管理人员素质等是有效提高病案首页质量的方法及监控措施。结论临床医师、病案管理人员及医院管理部门的共同努力,才能显著提高病案首页的正确性,是有效利用病案信息的保障。
Objective To find ways to improve the quality of the first page of medical records and monitoring measures so that the medical record information can be effectively used. Methods According to “the first page of inpatient medical record to fill in the request”, the first page of medical records quality management analysis. Results The first page of the medical records was mostly caused by the lack of conscientiousness of the record keeper, the lack of familiarity with the medical record writing norms, the quality control department in the department and the lack of personnel in the record management posts. Strengthening the bilingual publicity of Uygur and Han languages, strengthening physician training, putting good information into and out of customs, resolving the shortage of medical record administrators, and improving the quality of medical record administrators are all effective ways to improve the quality of the first page of medical records and monitoring measures. Conclusion The joint efforts of clinicians, medical record managers and hospital management departments can significantly improve the accuracy of the front page of medical records and ensure the effective use of medical record information.