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病案首页集中了病案中的主要信息,是病案中最重要、最核心的部分,及时正确地书写其中的每一个栏目是病案质量的重要保证因素之一,是病案首页计算机管理、信息资源得到充分利用的关键。由于诊断栏是进行疾病分类编码和统计数据的基础,也是费用计算和医疗保险赔付的根据,故在书写时能否做到规范、准确、完整、真实极为重要。
The first page of the medical records focuses on the main information of the medical records and is the most important and core part of the medical records. It is one of the important guarantee factors for the timely and correct writing of each part of the medical records. It is the first medical computer management and the sufficient information resources The key to use. As the diagnostic column is the basis for coding and statistical classification of diseases, as well as the basis for calculation of expenses and medical insurance payments, it is extremely important that the standardization, accuracy, completeness and truth be achieved in writing.