摘要
卫生部为医疗信息的标准化,分别于1990年、2001年和2011年3次修订定了全国统一的住院病案首页。从新版的病案首页增加的内容,如:组织机构代码、入院途径、入院情况等内容可见卫生部配合深化医改的决心;从删除出院情况、"HBsAg"、"HCV-Ab"、"HIV-Ab"等项目,又可见其简化统计内容,减少主观判断的良苦用心。医疗机构填写好病案首页责无旁贷,利国、利民,也有利于医院自身信息化建设。
For standardization of the health information,the Health Ministry compiles the front sheets of inpatient three times in the last two decades.From the additional contents of ＇code of organization＇,＇admission channel＇,＇admission condition＇,it shows the Health Ministry＇s resolution to support further medical reform.It can be realized that the ministry tries to make it more reasonable from some items deleted such as ＇discharged condition＇,＇HBsAg＇,＇HCV-Ab＇,＇HIV-Ab＇and so on.It is the responsibility for each hospital to fill well the contents of the front sheet and the hospital will be benefited from it.
出处
《中国病案》
2012年第2期6-8,共3页
Chinese Medical Record
关键词
病案首页修订
出院诊断
入院情况
疾病编码
The front sheet of medical records
Discharged condition
Admission condition
Disease code
