摘要
病案质量是衡量医疗质量的客观依据,也是医疗质量管理的热点和难点工作。病案首页浓缩了整份病案中的重要内容,是医院医疗质量和管理质量的集中体现。病案首页是病人出院后诊断与治疗的总结,也是疾病分类和医疗统计工作的原始资料。病案首页的设计集中体现了病人身份识别、病案资料检索、医院管理、医疗质量评价、统计等各方面的需要。因此病案首页的填写准确、完整与否对病案管理及医院管理影响很大。
Record quality is a measure of quality of care based on objective, it is also medical quality management, hot and difficult work.IT is concentration of the entire medical record medical record of the important content, it is also hospital medical quality and a concentrated expression of the quality of management~ Medical Records Home is summary of diagnosis and treatment of patients after discharge,it is also Classification of diseases and medical statistics of the raw data. Design of medical records home page embodies the identification of patients, Medical record data retrieval, medical quality Assessment, statistics the vafious＇s needs. The complete and accurate medical record, complete or not of case management and hospital management of a great impact.
作者
许春芝
XU Chun-zhi （Information Department,No.88 Hospital of PLA,Tai＇an 271000,China）
出处
《医学信息》
2010年第18期3283-3284,共2页
Journal of Medical Information
关键词
病案首页
作用
Medical Records Home
Effect
