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目的根据卫生部要求2012年我院更换新病案首页,为探讨新版病案首页填写问题及对策,不断提高新病案首页采集质量,使首页信息更好的服务医疗统计、临床科研、医疗质量评估等领域。方法病案首页是医疗统计的依据,是病案信息的反馈窗口,是统计医疗工作质量的原始资料,病案质量检查及医疗质量评估是对新病案首页进行质控,将问题反馈科室进行改进。结果病案首页信息是至关重要的,新病案首页更加符合《统计法》、医院管理、国际疾病分类ICD-10的要求,规范书写病案首页势在必行。结论通过加强病案首页质量填写的培训,使得各级医师认识到认真填写病案首页的重要性及对工作态度的责任心,使病案首页的质量明显提高,确保统计数据真实可靠、准确有效。
Objective According to the request of the Ministry of Health, the first page of the new medical record in our hospital was changed in 2012 to continuously improve the first page of the new medical record collection and countermeasures so as to continuously improve the collection quality of the first page of the new medical records and make the homepage information better service medical statistics, clinical research, medical quality assessment . Methods The first page of medical record is the basis of medical statistics, which is the feedback window of medical record information. It is the original data of the quality of statistical medical work. The medical record quality inspection and the medical quality assessment are the quality control of the first page of the new medical record and the improvement of the feedback department. Results The first page of the medical records is of crucial importance. The first page of the new medical records is more in line with the requirements of the Statistical Law, the hospital management and the International Classification of Diseases ICD-10. It is imperative to standardize the first page of medical records. Conclusion By strengthening the training of the first page of the medical records, the doctors at all levels are aware of the importance of filling the first page of the medical records seriously and the sense of responsibility for the work attitude so that the quality of the first page of the medical records is obviously improved and the statistical data is reliable and accurate.