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规范病案首页的填写,提高病案的整体质量。对病案首页填写中发现的问题进行统计、归类、分析。结果发现病案首页缺陷主要以诊断信息错填为主,其他各项信息以漏填为主,明确了整改方向,制定了整改的对策及方法。病案首页各项数据填写的准确性,关系到各种医疗统计数据的准确性,更是处理医疗纠纷、评定伤残等级和医疗保险赔偿的法律依据。
Fill the first page of the medical record and improve the overall quality of the medical record. The first page of the record to find out the problems found in the statistics, classification, analysis. The results showed that the first page of the medical record mainly consisted of the wrong diagnosis information. The other information was mainly based on the omission and filling, which clarified the rectification direction and formulated the countermeasures and methods for rectification. The accuracy of the data on the first page of the medical record is related to the accuracy of various medical statistics. It is also the legal basis for handling medical disputes, assessing the level of disability and medical insurance compensation.