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| 对广东省病案首页改进设计的建议 | |
| 引用本文： | 钟汝华,杨柳明. 对广东省病案首页改进设计的建议[J]. 中国病案, 2010, 11(3): 13-13 |
| 作者姓名： | 钟汝华 杨柳明 |
| 作者单位： | 广东省廉江市人民医院,廉江市,524400 |
| 摘 要： | 目的分析病案信息管理中的难点及影响因素,确保病案信息的完整性和科学性。方法前瞻性与回顾性调查分析我院2008年1月-2008年12月反复出错的病案首页项目。结果转科科别（转科时间）、门（急）诊医生（工号）、手术操作记录、产科分娩婴儿记录、肿瘤专科病人治疗记录、费用是错误率较高的填写项目也是病案首页信息管理中的难点。概念不清及病案首页不科学设计是错填、漏填的主要原因。结论提高对病案信息重要性的认识,科学设计病案首页,加强病案信息管理知识培训,严把病案信息录入关,健全监督检查制度是提高病案首页填写质量的有效措施。 |
| 关 键 词： | 病案首页 设计 管理 |
Improved Design of the Front Sheet of Medical Records |
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| Zhong Ruhua,Yang Liuming. Improved Design of the Front Sheet of Medical Records[J]. Chinese Medical Record, 2010, 11(3): 13-13 | |
| Authors: | Zhong Ruhua Yang Liuming |
| Affiliation: | Zhong Ruhua,Yang Liuming.People's Hospital of Lianjiang County,Guangdong Province,524400 |
| Abstract: | Objective To find the difficulties and related reasons in the management of medical records so that medical records with integrity and scientific nature can be input into the medical records management system of Guangdong Province conveniently.Methods Items in the front sheet of medical records which were completed from January to December in 2008 were analyzed by prospective and respective study.Results Transferred department (time),doctors (work number) in outpatient (emergency) department,operation recor... |
| Keywords: | the front sheet of medical records design management thened quality of medical records importance |
| 本文献已被 CNKI 维普 万方数据 等数据库收录！ | |