病案首页是病案的缩影,完整、准确地填写好病案首页,是提高医疗统计和科研检索的基础,本文将病案编目及录入工作中发现的病案首页质量常见问题分析如下: 一、病案首页常见质量问题 (一)疾病诊断 1.疾病诊断选择不准。如:十二指肠溃疡伴出血,医师诊断为第一个诊断为“消化道出血,第二个诊断“十二脂肠溃汤”。形成原因有二:(1)追求治愈率指标,有意选择患者能够达到临床治愈的诊断; The medical record home page is the epitome of the medical record. Completely and accurately filling out the first page of the medical record is the basis for improving medical statistics and scientific research. This article analyzes the common problems of the medical record found in the case record and entry work as follows: First, the common case record Problems (I) Disease diagnosis 1. Disease diagnosis is not allowed. Such as: duodenal ulcer with bleeding, the doctor diagnosed as the first diagnosis of “gastrointestinal bleeding, the second diagnosis, ”12 fat soup". There are two causes: (1) the pursuit of cure rate indicators, intentional Select the patient to achieve clinical cure diagnosis;