摘要
病案首页和病案记录及时签字,确保病案内容资料完整、正确、规范,才能及时归档,容易查找,不易丢失病案。经过各级医师审签确认后的病案资料,方可为医疗、科研、教学、社会保险、法律部门、医院管理、经济方面提供内容正确的病案信息。通过人性化管理和为签字医师提供满意的服务,可以督促各科主任和临床医师及时完成病案首页审核签字工作,以达到加强病案首页签字的监控管理。
To urge the department directors and clinicians completed signature work in the home pages of medical records in time through human-based management and provide satisfactory service for sign physicians,thus to strengthen the quality supervision management of signature work in the home pages of medical records.The timely signature of home pages and records of medical records,ensure the correct,complete and standardized of the content of medical records,then could we get timely file,easy to find,and difficult of missing records.The materials of medical records after signing confirmation of the physicians at all levels could provide the correct medical records information for aspects such as medical treatment,scientific research,teaching,social insurance,legal department,hospital management and economic aspect.
出处
《中国病案》
2014年第5期9-10,共2页
Chinese Medical Record
关键词
病案首页
审签
病案信息
信息服务
Home pages of medical records
Signature
Medical records information
Information service