病案首页填写质量与医疗数据统计  

The Filling Quality in Front sheet of Medical Record and Accuracy of Medical Statistical Data

作　　者：张存仁[1,2] 董海军[1,2] 王彩萍[1,2] 

机构地区：[1]延安大学医学院第二附属医院,榆林市718000 [2]陕西省榆林市第一医院

出　　处：《中国病案》2010年第9期37-38,共2页Chinese Medical Record

摘　　要：目的病案首页填写质量能保证医疗统计数据准确、完整。方法对病案首页填写中存在问题分析产生的原因,制定改进措施。结果实施有效措施后病案首页填写质量明显提高。结论病案首页填写准确、完整关系到医疗统计数据能否达到准确,是医疗质量和效率的评估依据。Objective To improve the filling quality in front sheet of medical record in order to guarantee accurate and complete medical statistical data. Methods Problems existed in filling quality of medical record were analyzed to develop countermeasures. Results With the implementation of effective measures,the filling quality in front sheet of medical record was improved significantly. Conclusion Accurate and complete information in front sheet of medical record correlated with exact medical statistical data,which was also the evaluation evidence of medical qualty and efficiency.

关 键 词：病案首页 缺陷 措施 

分 类 号：R197.3[医药卫生—卫生事业管理]