浅谈病案首页填写与录入中的问题与解决方法

目的规范病案首页的填写,提高病案质量。方法对病案首页填写中发现的问题进行登记、归类、分析,制定一系列有效措施。结果通过有效措施的实施,病案质量有了明显提高。结论病案首页各项数据填写的准确性,关系到各种统计报表的准确性,更关系到出现纠纷时该病案的法律性。只有严格执行各项制度,从思想上和业务上对相关人员进行教育和培训,才能使病案工作不断提高和改进。

ON THE PROBLEMS AND SOLUTIONS OF THE FIRST PAGE OF CASE FILLED WITH THE INPUT

Objective In order to improve the quality of medical record by filling in the first page of the medical record standardly. Methods Register, classify and analyze the problems of Medical Record first page that we found,institute a series of effective measures. Results the quality of medical record improved markedly by implementation of effective measures. Conclusion the accuracy of the filling data of the first page of medical record, related to the accuracy of various statistical reports,will influence the le- gal rule of the cases when the dispute appeared. It is possible to enhance and improve the medical record work only by carrying out the system strictly,and the education and training for the related personnel from thought and profession are also very important.