摘要
目的寻找提高病案首页质量的方法及监控措施,使病案信息能有效利用。方法根据《住院病案首页填写的要求》,对病案首页质量管理进行分析。结果病案首页错误多由录入员责任心不强、医师对病历书写规范不熟悉、科室质控流于形式、病案管理岗位人员缺乏所致。加强维汉双语宣传、强化医师培训、把好信息录入关、解决病案管理人员短缺、提升病案管理人员素质等是有效提高病案首页质量的方法及监控措施。结论临床医师、病案管理人员及医院管理部门的共同努力,才能显著提高病案首页的正确性,是有效利用病案信息的保障。
Objective To find ways to improve the front sheet of medical record quality and control measures and make effective use of medical record information.Methods Analysing quality of the front sheet of medical record according to ＂Complete requirements of the front sheet of medical record＂.Results The errors of the front sheet of medical record due to no responsibility,not familiar with writing,quality control become a mere formality and lack of medical records managers.Strengthening Chinese-Uigur publicity,strengthening physician training,improving information input quality,solving the lack of medical record managers and improving the quality of medical record are effective methods to improve the quality of the front sheet of medical record.Conclusion Improving the accuracy of the front sheet of medical record significantly by joint efforts of clinician,medical record managers and hospital management department,and protecting the effective use of medical record information.
出处
《中国病案》
2011年第6期29-30,共2页
Chinese Medical Record
关键词
病案首页
病案质量
有效利用
The front sheet of medical record
Medical record quality
Effective use
