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病案管理是医院管理工作中的重要组成部分,内容完整的病案不仅是医务人员诊疾病的依据,也是医学研究的宝贵财富,还是处理医疗纠纷、评定伤残等级和医疗保险赔偿的法律依据。而病案首页是病案中信息最集中、最核心的部分,无论是统计报表、还是病案检索都需要病案首页提供的信息,因此,病案首页的填写对病案质量的影响是不可忽视的,我院自“军卫一号”工程运行后,为加强病案首页的质量管理,病案室在医院领导下采取了一些措施,收到了一定成效。
Medical record management is an important part of hospital management. A complete medical record is not only the basis for medical personnel to diagnose diseases, but also a valuable asset of medical research, or the legal basis for handling medical disputes, assessing the level of disability and medical insurance compensation. The medical record homepage is the most centralized and most central part of the medical record. No matter whether it is statistical reports or medical record retrieval, the information provided on the front page of the medical record is required. Therefore, the impact of the completion of the medical record home page on the quality of the medical record cannot be ignored. After the “Military and Guardian No.1” project was put into operation, in order to strengthen the quality management on the front page of the medical record, the medical record room took some measures under the leadership of the hospital and received certain results.