电子病案首页存在的问题及改进意见

Problem and improvement in the front sheet of the electronic medical record

目的:通过对电子病案填写的质量监控,规范病案首页的正确书写,提高病案书写质量。方法:对2006年5月～2008年2月出院的归档并进行质检的74458份病案统计,分析。结果:74458份电子病案首页有5325份存在问题,占7.2%。结论:加强各级医师认识病案填写的重要性,提高电子病案首页书写质量。

Objective： By the quality monitoring of filling in the Electronic Medical Record, the correct filling in the front sheet of the medical record was standardized and the quality of filling-in was improved. Methods： 74 458 cases discharged from hospital between from May 2006 to Feb 2008 were statistical analyzed. Results： In these 74 458 cases, there were 5 325 defected cases, the rate was 7.2%. Conclusion： In order to improve the quality of the front-sheet in medical record, we should strengthen the consciousness of all doctors to make them know the importance of filling in front sheet correctly.