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对2013年3月304份住院病案首页中的疾病诊断相关项进行检查,发现病案首页填写的主要缺陷以出院主要诊断选择错误、出院诊断和医院感染漏填为主。增强医师责任心、加强医师主要诊断选择原则及病历书写的培训、加强编码员与临床医师的沟通,充分利用三级查房制度及病历质量监控等措施,才能提高老年病区病案首页填写的质量。
March 2013 304 cases of inpatient home page disease diagnosis related items to check and found that the first page of the main medical record to fill the main defects in the diagnosis of the main choice of discharge errors, discharge diagnosis and hospital-based infection leak-based. Enhance the physician’s sense of responsibility, strengthen the doctor’s principle of diagnosis selection and training of medical record writing, strengthen the communication between the coder and the clinician, make full use of the three rounds of ward rounds and medical records quality control measures to improve the quality of the first page of the medical record in the geriatric ward .