目的分析病案首页质量缺陷,提出改进措施。方法抽查了2005年1月~6月全院25个科室出院病案首页15342份。结果15342份病案首页中,有质量缺陷672份,占抽查病案首页的4.3%;出院情况缺陷136份,占病案首页质量缺陷的20.0%;手术操作名称缺陷112份,占病案首页质量缺陷的16.6%;病理诊断缺陷97份,占病案首页质量缺陷的14.4%。结论加强质量教育和管理力度可以提高病案首页质量。 Objective To analyze the quality defects on the front page of medical records and put forward improvement measures. Methods A random sample of 15,342 cases from the January 25 to the end of June 2005 in 25 hospitals across the hospital. Results Of the 15,342 cases, there were 672 quality defects, which accounted for 4.3% of the total number of samples on the front page; 136 defects were discharged from the hospital, which accounted for 20.0% of the quality defects on the front page of the case; 112 were defective in the name of the operation, accounting for 16.6% of the first page of the case. %; pathological diagnosis of 97 defects, accounting for 14.4% of the first case quality defects in the case. Conclusion Strengthening quality education and management can improve the quality of medical records.