提高病案首页填写质量 保证医疗信息的准确性

Improve filling quality of front page of medical records and ensure the accuracy of medical information

目的规范病案首页填写内容,确保医院病案信息的真实、准确。方法对病案首页信息填写常见缺陷进行评析。结果病案室质控医师对终末病历进行逐份评估,病案录入人员在录入时检查首页填写情况,定期将检查结果进行统计、总结,及时将结果反馈于各临床科室,由医务处负责督促改正。结论通过长期对病案首页质量的检查-反馈-督促改正,在全院树立全面(全院、全员、全过程)质量管理意识,提高病历书写质量,使病案首页填写内容准确、完善,确保统计数据的真实性、准确性,提高医疗质量。

Objectives To standard the filling content of front page of medical records and to ensure the truth and accuracy of medical records information Methods to analyze the flaw commonly seen in the filling of front page of medical records. Results doctors who response the quality control evaluate every final medical records; people who check the filling situation when entering the information; staffs from department of medical records add up and summary the examine results regularly and give feedback to clinical departments, which supervise and urge for amending by medical affairs department. Condusions to establish overall （the whole hospital; all staffs in hospital; the whole process） quality management consciousness and to improve writing quality of medical records through check - feedback - amending the front page quality; to ensure the filling content are accuracy and perfect and make sure the truth, accuracy of statistic data for improving medical quality.