摘要
目的设计科学合理的病案首页信息系统,提高病案统计质量。方法通过标准字典库提供规范性诊断,通过信息共享、自动生成、在线控制等功能减少录入环节。结果应用信息化的病案首页,可以提高病案首页填写质量,确保各类统计报表数据的真实性、准确性、可靠性。结论应用病案首页信息系统,不仅减少病案统计人员的重复劳动和人力物力的浪费,提高工作效率和工作质量,而且,还能从根本上降低病案首页缺陷的发生率。
Objective To design a scientific information system of the front sheet of medical records, and improve the statistic quality of medical records. Methods Providing normative diagnosis by standard wordbook, decreasing the record links by information sharing, automatic generation, online control. Results The application of the informationalized front sheet of MR can improve the quality of writing, ensure the reality, accuracy and credibility of all kinds of statistical data. Conclusion The application of information system of the front sheet of medical records can not only avoid repeat work, improve efficiency and quality of the work, but also can radically reduce the defects incidence rate in writing.
出处
《中国病案》
2011年第11期34-34,33,共2页
Chinese Medical Record
关键词
病案首页
信息系统
The front sheet of medical record
Information system
