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目的探讨病案首页信息标准化建设。方法摇根据现行病案首页信息统计分析,对有关标准不一致处提出建议。结果摇对病案首页信息逐项提出要求及有关标准。结论病案首页信息的各项目必须统一要求、统一标准,以便医院间病案信息交流与资源共享。
Objective To explore the standardized construction of medical records on the front page. According to the statistical analysis of the current medical records on the home page, the method shakes recommendations on the inconsistency of relevant standards. The result shakes the one-by-one requirements and related standards for the top-level information on the medical record. Conclusion The items on the first page of the medical record must meet the requirements and standards in order to facilitate the exchange of information and resources among hospitals.