2012版病案首页填写存在的问题及改进措施

病案首页的规范化填写是临床医务人员必须具备的技能之一。本文以卫生部修订的2012版病案首页项目内容为根本,按卫生部病案首页填写要求,对某院2012版住院病案首页主要修订项目内容及易出现的填写缺陷问题,如付费方式、新生儿出生、入院体重,月龄、颅脑损伤昏迷时间、诊断及手术信息等项目填写质量进行了专项检查,并针对存在的问题进行归纳总结得出结论,应在院内临床科室及相关科室加强2012版病案首页的修改项目内容及填写要求的交流,宣传病案首页规范填写的重要性及意义,进一步增强病案首页书写质量意识,促进医疗机构的医疗质量管理更安全和病案质量管理工作更完善。

The problems and relevant improving measures existing in the filling of 2012 edition of Medical Record homepage

The standard filling of medical record homepage is one of the necessary skills of clinical medical personnel.This article made a special check-up to the revised items and filling defects in homepages such as payment,newborns,weight,sage,coma time,diagnosis and operation of craniocerebral injury,and summarized problems existing in the quality of homepage filling,concluded that we should strengthen the communication of the revised items and filling requirments,broadcast the importance of the standard filling of medical record homepage.To improve the awareness of the filling quality of homepages,make the medical quality management safer and the management of medical record perfect.