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目的规范填写病案首页,保证统计数据的准确性。方法返聘两位退休专家对终末病案逐份进行评审。病案人员在录入时检查病案首页的填写情况,每月将检查到的缺陷内容及时反馈各临床科室,督促改正。结果促进了住院病案首页填写的规范化。结论通过加强对病案首页填写的学习,各级医师对病案首页填写重要性的认识,首页书写质量与当事人奖金挂钩,加强与临床医师的沟通,及时反馈等措施,使病案首页的质量明显提高,确保统计数据的真实和准确。
The purpose of the specification is to fill in the first page of the medical record to ensure the accuracy of the statistical data. METHODS: Two retired experts were recruited to review the final case. The medical record holders check the filling status of the first page of the medical record at the time of entry. Each month will check the content of the defect and promptly report back to each clinical department and urge them to make corrections. As a result, the standardization of the first page of inpatient medical records was promoted. Conclusion By strengthening the study on the top of the medical record, doctors at all levels recognize the importance of filling out the first page of the medical record, linking the quality of the home page writing with the bonus of the client, strengthening the communication with the clinician, and providing timely feedback and other measures, so that the quality of the first page of the medical record is significantly improved. Ensure that the statistics are true and accurate.