摘要
目的指导临床医师正确填写病案首页,为医疗质量控制提供依据,从而提高医院的诊疗水平。方法在病案首页库中有针对性的检索3000份病案,通过筛选,抽取100份进行检查。结果 5项诊断指标在病案首页的填写中均存在程度不等的缺陷。结论加强对病案首页的质量监控,对真实反映医疗统计指标,切实提高医疗质量管理水平具有重要意义。
Objective To direct clinicians completed the front sheet of medical records correctly,provide a basis for medical quality control and increased the level of the diagnosis and treatment.Methods The author aimed for 3000 and 100 medical records were selected.Results The 5 diagnostic index of front sheet of medical records had various defects.Conclusion It is important to strengthen quality control of the front sheet of medical records,and it has important significance for truly reflecting the medical statistical indexes and increasing the medical quality management level.
出处
《中国病案》
2011年第4期26-27,共2页
Chinese Medical Record
关键词
病案首页
诊断指标
质量监控
统计分析
The front sheet of medical records
Diagnostic index
Quality control
Statistical analysis
