病案首页与单病种管理

The Front Sheet of Medical Record and Mono-disease Management

目的病案首页是病案的窗口,是病案的精髓;是信息交流的枢纽。方法查找病案首页信息中存在漏填、错填和填写不规范的问题影响了单病种标准化管理。结果通过对单病种的质量控制,对病案首页存在的缺陷进行核查,提出改进建议,提高了病案首页的书写的质量,保证单病种的标准管理。

Objective The front sheet of medical record is the window and essence,which also plays a key role in information communication. Methods The missed,mistake and irregular information in front sheet of medical record which affected the standardized management of mono-disease was found. Results Through improving the quality control of mono-disease and checking defects in front sheet of medical record,improvement suggestions were proposed to enhance the writing quality and achieve standardized management of mono-disease.