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目的完善病案首页管理,确保统计质量的准确性和完整性。方法抽查了2003年7—12月全院25个科室的出院病案首页8530份。结果首页错误500份,占55.71%;填入不确切和不全的病案首页200份,占不合格的病案首页22.29%;填入漏项首页的197份,占不合格病案首页的21.96%。结论通过严格把关和定期培训可以提高病案首页质量。
Objective To improve the management of medical records at the top of the case to ensure the accuracy and completeness of statistical quality. Methods A total sample of 8,530 hospital cases from the 25 departments of the hospital from July to December 2003 was collected. The results of the home page error 500, accounting for 55.71%; fill in the inaccurate and incomplete first 200 cases of the medical record, accounting for 22.29% of the unqualified record; fill in the missing item home page 197, accounting for 21.96% of the unqualified case of the home page. Conclusion Through strict control and regular training, the quality of the medical record can be improved.