34家医院病案首页存在问题分析及改进措施

目的：云南省卫生厅为提高各级医院的诊疗及管理水平，组织相关人员以卫计委修订的2012版病案首页项目内容为基础和填写要求，调查了解云南省二、三级综合医院病案首页信息填写水平及缺陷，针对性的整改，尽快规范病案首页的填写。方法对省内34家二、三级医院各抽取20份出院病案，就病案首页内容进行检查。结果检查780份病案，发现缺陷病案首页共512份，达65.6%。发现患者基本信息、诊疗信息、费用信息和编码填写存在诸多缺陷。结论卫生行政部门加强管理和引导，组织有针对性的培训和检查，督促医务人员掌握病案首页填写规范和技能，取得较好的效果。

Problem Analysis and Improvement Measures of the Front Sheet of Medical Records about 34 Hospital

Objective On the basis of the front page of medical records content which revised by the ministry of health in 2012,Yunnan province health department organize relevant personnel investigate defect information of the front sheet of medical record of secondary and tertiary general hospital.Methods Examing the front sheet of medical record of 34 secondary and tertiary general hospitals.Each hospital extracts 20 medical records.Results A total of 512 defects in 780 medical records,and up to 65.6%.There are many defects such as basic information of the patients,diagnosis and treatment information,cost information and the codes.Conclusion We should strengthen the writing quality consciousness about the front sheet of the medical record by organizing the targeted training and improvement,master the specification and skills of writing the front sheet of medical record to get good effect.