本文介绍了我院的一种电子病历首页审核模式。该模式在医院电子病历系统建设背景下,坚持国际疾病分类“编码主导”、分类诊断与临床诊断“求同存异”、病案管理人员与医护人员良好“沟通互动”、审核过程“分步实施”为原则,并在多层次、多角度培训的基础上得以循序渐进地进行。模式的实施优化了病案管理与临床科室工作流程,促进了全院病案管理理念转变,推动了医院信息系统建设,提高了工作效率,取得了良好效果。 This article describes our hospital a home electronic medical records review mode. The model in the hospital electronic medical record system construction background, adhere to the international classification of diseases “code-driven ”, classification and clinical diagnosis “seek common ground while reserving differences ”, medical record management and medical staff “Step by step implementation” as the principle, and in a multi-level, multi-angle training based on a gradual process. The implementation of the model has optimized the medical records management and workflow of clinical departments, promoted the transformation of the hospital’s case management concept, promoted the construction of hospital information system and improved the work efficiency, and achieved good results.