病案首页中几个问题的探讨

A Discussion on the Problems in the Front Sheet of the Medical Records

病案首页是病案的小结和简要提纲,是病案室进行各项登记,编目,索引的依据,是统计的最原始资料,因此正确填写病案首页,不但关系到病案资料的准确性和完整性,而且直接影响统计结果,也影响对一个医院的医疗质量和效率的评估,因此如何正确填写病案首页是一个不容忽视的问题。

the front sheet of a medical record is the summary of all information; Registration, category, and index for the medical record are solely based on it. It also is the initial record for statistics. Correctly filling in the front sheet will lead to accuracy and integration of the medical records, which also directly affects the statistic result and has a profound meaning in the assessment of healthcare quality and efficiency of the hospital. Therefore, filling in the front sheet is an issue that cannot be ignored.