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病案首页手术及操作一栏共有以下8个项目,(1)手术及操作编码;(2)手术及操作日期;(3)手术级别;(4)手术及操作名称;(5)手术及操作医师;(6)切口愈合等级;(7)麻醉方式;(8)麻醉医师。除第(1)项外,其余7项均由临床医师填写,在实际工作中发现,在由医师填写的7项中,手术及操作日期、手术级别、手术及操作名称、切口愈合等级这4项的填写存在较多问题,现就这4个方面的问题分析报告如下。
The first page of the case record of operation and operation includes the following 8 items: (1) Surgical and Operational Coding; (2) Surgical and Operational Date; (3) Operational Grade; (4) Surgical and Operational Names; (5) Surgical and Operating Physician ; (6) incision healing level; (7) anesthesia; (8) anesthesiologist. In addition to item (1), the remaining 7 items were filled in by clinicians. In actual work, among the 7 items filled in by doctors, the operation and operation dates, the operation level, the operation and operation names, and the degree of incision healing were 4 There are many questions to fill in the items, the analysis of the problems in these 4 aspects is as follows.