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病案首页是对病案的整体概括,如果病案首页信息填写不完整或者是存在问题,将会对后期的数据统计和医院管理带来极大的不便。电子病案首页是能够直接反映患者病情的内容,对于后期统计报表的制定和医院管理科研的研究都有着十分重要的作用。但是从目前的情况来看,我国一些医院在电子病案首页填写中出现了一些问题。笔者将会针对电子病案首页中存在的问题进行简单的分析,并对造成这些问题的原因和提高病案首页质量的措施与对策等内容进行具体的分析和阐述。
The first page of the medical record is the overall summary of the medical record. If the first page of the medical record is incomplete or has some problems, it will bring great inconvenience to the subsequent data statistics and hospital management. E-Medical Record Home is able to directly reflect the content of the patient’s condition, for the development of statistical reports and hospital management research has a very important role. However, from the current situation, some hospitals in our country have some problems appearing in the first page of electronic medical records. The author will conduct a simple analysis of the problems existing in the first page of the electronic medical record and make specific analysis and elaboration on the causes of the problems and the measures to improve the first page of the medical record and countermeasures.