8487份病案首页填写缺陷分析  

Analysis of the Defects in the Front Sheet of 8487 Medical Records

作　　者：侯丹岩[1] 刘元[1] 

机构地区：[1]辽宁省大连市友谊医院病案室,大连市116001

出　　处：《中国病案》2010年第4期25-25,24,共2页Chinese Medical Record

摘　　要：目的规范病案首页填写,提高信息统计质量。方法将病案首页填写中的问题进行分析,改正。结果通过有效的改正措施,病案首页填写质量显著提高。结论病案首页是医疗信息的载体,要保证医疗信息的准确性。Objective To standardize the writing in the front sheet of medical records and improve its quality.Methods Problems in the front sheet of medical records and the causes were analyzed,and effective countermeasures were taken as well.Results The writing quality of front sheet in the medical records was improved greatly.Conclusion The front sheet of medical records,the carrier of medical information,whose quality can be improved markedly by strengthening the inspection and training on it,so that the accuracy of medical information can be ensured to better serve for the medical services,teaching,research and hospital management.

关 键 词：病案首页 缺陷 分析 

分 类 号：R197.3[医药卫生—卫生事业管理]