计算机病例分型数据变量的采集,主要来自病案首页中的有关信息。按规范要求填写的病案首页,不仅归纳概括了病人的基本情况,而且能够比较全面、真实的反映病人住院期间的诊断、治疗、手术、护理及病情变化情况。在没有实现计算机联网的医院,首页的一部分由住院处在办理病人入院 The collection of computer case classification data variables mainly comes from relevant information in the first page of medical records. The home page of medical records completed according to the requirements of the standard not only summarizes the basic conditions of the patient, but also can reflect the diagnosis, treatment, surgery, care and changes in the patient’s condition during the hospitalization process. In a hospital that does not have a computer network, a part of the home page is admitted to the hospital by the inpatient office.