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病案首页是病员住院期间诊治疾病经过的集中概括,是进行医疗信息管理和医疗业务统计的最可靠资料。其填写质量直接影响着统计报表的准确性,也客观地反映出医院医疗质量的高低。根据医院分级管理的要求,我们通过工作实践并结合医院实际采取了一系列提高病案首页填写质量的措施,收到了较好的效果。1 在病案首页填写内容上应力求全面把握重点
The medical record homepage is a centralized summary of the diagnosis and treatment of illnesses during the hospitalization of patients. It is the most reliable data for medical information management and medical service statistics. The quality of the fill directly affects the accuracy of the statistical report, and also objectively reflects the level of hospital medical quality. According to the requirements of the hospital’s classification management, we have adopted a series of measures to improve the filling quality of the top of the medical records through work practice and in combination with the actual conditions of the hospital, and have received good results. 1 to fill in the content on the first page of the medical record to strive to fully grasp the key