摘要
病案首页是患者接受检查、诊断、治疗、护理以及病情发生、发展和转归详细系统的缩影。是整个病案中信息最集中、最主要、最核心的部分。同时病案首页统计在医疗、教学、科研及医疗纠纷中发挥着非常重要的作用。但在实际工作中,临床医师往往忽视病案首页的重要性,首页质量缺陷、漏填、错填现象比较普遍,影响了病案统计信息的准确性。文章通过抽查2003￣2005年23 808份外科住院病历,对影响病案首页质量的原因进行分析,提出相应的管理措施,增加病案首页内涵,提高医师业务素质,使病案首页内容完整准确达到应有的质量标准。
The first page of medical recording is the reduction of the process of examination, diagnosis, therapy and nursing and the reduction of the process of the diseases. Therefore, the first page is the most nuclear part of medical recording, and plays an important role in medical teaching, research and medical dispute. In practical work, the clinical physicians often ignore the importance of medical recording. Some items on the first page are often missed out 23808 medical recordings or mistaken, so the quality of medical recording is influenced. This paper surveyed of surgery from 2003-2005, and analyzed the factors influencing the quality of the first page of medical recording. This paper presented with some control measures, increasing the connotation of the first page of medical recording, improving the professional quality of the medical physicians and standardizing the content of the first page.
出处
《南京医科大学学报（社会科学版）》
2006年第3期224-226,共3页
Journal of Nanjing Medical University（Social Sciences）
关键词
病案首页
缺陷
质控
first page of medical recording
defect
quality control
