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目的:规范病案首页的正确书写,提高病案书写质量。方法:由病案室及转科医师随机抽取出院病案3 046份进行首页内容专项检查。结果:3 046份被查病案中,病案首页填写存在问题的共748份,占所查病案的24.56%。结论:为提高病案首页书写质量,应不断加强对医务人员责任心、工作素质的培养,提高病案质量意识及法制观念,强化医院三级质控。
Objective: To standardize the correct writing of the first page of the medical record and to improve the quality of the medical record writing. Methods: 3 046 cases were randomly selected from medical records and transfer physicians to carry out special examination of the contents of the home page. Results: Of the 3 046 cases examined, 748 were filled in with the existing problems, accounting for 24.56% of the cases examined. Conclusion: In order to improve the writing quality of the first page of the medical records, we should continue to cultivate the sense of responsibility and quality of the medical staff, raise awareness of the medical records and the concept of the legal system, and strengthen the quality control of the third hospital.