病案首页缺陷对医疗信息质量的影响  

The Influence of the Front Sheet of Medial Records Defects on Medical Information Quality

作　　者：李京淑[1] 纪博雅[1] 房迎华[1] 

机构地区：[1]佳木斯大学附属第二医院

出　　处：《中国病案》2011年第4期27-27,25,共2页Chinese Medical Record

摘　　要：目的通过分析病案首页存在问题,进一步提高病案信息质量。方法按2001年卫生部颁发的病案首页填写标准,对某院病案首页信息填写质控、检查分析。结果检查3864份病案首页,323份存在缺陷,归纳出影响病案首页填写质量的因素。结论通过医院管理部门、病案管理人员和临床医师的共同努力,确保病案首页的准确性,才能保证医疗信息的质量。Objective To analyze the existing problems of the front sheet of medial records,further improve the quality of medical record information quality.Results Out of 3864 examined medical records,323 has quality defects.Summed up the impact factor of the quality of the front sheet of medical records.Conclusion Through the co-work of hospital management section,medical record manager and clinicians,ensure the accuracy of the front sheet of medial records and the quality of medical information.

关 键 词：病案首页 医疗信息 准确性 

分 类 号：R197.3[医药卫生—卫生事业管理]