摘要
病案首页是病案的精华,是医院为各方面应用最多、使用频率最高的信息载体。病案首页填写质量的高低直接反映临床医师医疗水平及医院管理水平的高低。本文通过剖析病案首页填写存在的较普遍的问题,结合临床实际提出了解决问题的对策。
The first page of medical records is the essence of the medical records. In a hospital, it is the information carrier in each aspect the application is at most and the usage frequency is tallest. The quality of the first page of medical records falling in directly reflects the level of the medical treatment and hospital control. From analyzing the widespread problems for the first page of medical records falling in and uniting the clinical actrual, I put forward some countermeasures for solving these problems.
关键词
病案首页
病案管理
问题
对策
first page of medical records
medical records management
problems
countermeasures
