《康复住院病案首页书写指南》团体标准解读  

Interpretation of Association Standard Standard for writing the first page of medical records

作　　者：曲冰[1] 郑洁皎[1] 周媚媚 毕霞 杨坚[3] QU Bing;ZHENG Jie-jiao;ZHOU Mei-mei;BI Xia;YANG Jian(Huadong Hospital Affiliated to Fudan University;Zhoupu Hospital Affiliated to Shanghai University of Medicine&Health Sciences;Shanghai Xuhui Central Hospital)

机构地区：[1]复旦大学附属华东医院 [2]上海健康医学院附属周浦医院 [3]上海市徐汇区中心医院

出　　处：《中国标准化》2023年第21期166-169,共4页China Standardization

基　　金：国家重点研发计划项目“主动健康和老龄化应对”重点专项“基于区块链的老年主动健康智能照护平台研究与应用示范”(项目编号:2020YFC2008700);上海康复医学临床医学研究中心项目(项目编号:21MC1930200)资助。

摘　　要：住院病案首页是病案信息中最集中、最核心的部分。随着医疗付费方式改革工作的进一步深入,对住院病案首页中疾病诊断和手术(操作)名称等关键信息的科学性、准确性提出了更高的要求。康复住院病案首页应具备康复诊疗特点,围绕患者功能障碍出现的状况,运用康复医学专业术语进行记录。为此上海市康复医学会标准化工作委员会发布团体标准《康复住院病案首页书写指南》,标准从康复医学住院病历首页书写基本要求、填写规范、编码规则方面提出了建议。The first page of the inpatient medical records is the most concentrated and core part of the medical record information.With the further deepening of the reform of medical payment methods,higher requirements have been put forward for the scientificity and accuracy of key information on the first page of the inpatient medical records,such as disease diagnosis and name of the operation.The first page of the rehabilitation inpatient medical records should have the characteristics of rehabilitation diagnosis and treatment,and use the professional terminology of rehabilitation medicine to record the situation of patients’dysfunction.The standardization working committee of the Shanghai Rehabilitation Medical Association issued the association standard Standards for writing the first page of medical records.The standard puts forward suggestions on the basic requirements for writing the first page of the inpatient medical records of rehabilitation medicine,filling specifications and coding rules.

关 键 词：病案首页 标准化 康复 

分 类 号：R197.323[医药卫生—卫生事业管理]