目的针对病案首页质量缺陷及原因进行分析,制定相应的病案首页规范化管理措施。方法抽查2005年6月~12月出院病案,对有缺陷的病案首页内容进行分析。结果4677份病案首页存在缺陷的有539份,缺陷率为11.54%。结论对书写病案首页的重要性认识不足和临床医师不熟悉ICD-10编码规则。因此,医院要加大对病案首页检查考核力度,以提高病案质量和医疗信息资源的真实性。 Objective To analyze the quality defects and causes of the first page of medical records, and formulate corresponding standardized management measures for the first page of medical records. Methods A random sample of patients discharged from June 2005 to December 2005 was analyzed. The contents of the first page of the defective medical records were analyzed. As a result, there were 539 defects in the 4677 medical records on the front page, and the defect rate was 11.54%. Conclusion The lack of understanding of the importance of the first page of the written case and clinicians are unfamiliar with ICD-10 coding rules. Therefore, hospitals should increase the examination and evaluation of the medical records to improve the quality of medical records and the authenticity of medical information resources.