病案首页二十年三次修订之对比  

Changes of the Front Sheets in the Last Two Decades

作　　者：吴韫宏 伍伟锋 

机构地区：[1]广西医科大大学第一附属医院,南宁市530021

出　　处：《中国病案》2012年第2期6-8,共3页Chinese Medical Record

摘　　要：卫生部为医疗信息的标准化,分别于1990年、2001年和2011年3次修订定了全国统一的住院病案首页。从新版的病案首页增加的内容,如:组织机构代码、入院途径、入院情况等内容可见卫生部配合深化医改的决心;从删除出院情况、"HBsAg"、"HCV-Ab"、"HIV-Ab"等项目,又可见其简化统计内容,减少主观判断的良苦用心。医疗机构填写好病案首页责无旁贷,利国、利民,也有利于医院自身信息化建设。For standardization of the health information,the Health Ministry compiles the front sheets of inpatient three times in the last two decades.From the additional contents of ＇code of organization＇,＇admission channel＇,＇admission condition＇,it shows the Health Ministry＇s resolution to support further medical reform.It can be realized that the ministry tries to make it more reasonable from some items deleted such as ＇discharged condition＇,＇HBsAg＇,＇HCV-Ab＇,＇HIV-Ab＇and so on.It is the responsibility for each hospital to fill well the contents of the front sheet and the hospital will be benefited from it.

关 键 词：病案首页修订 出院诊断 入院情况 疾病编码 

分 类 号：R197.3[医药卫生—卫生事业管理]