病案首页中信息填写完整的价值与意义分析

王达光



病案首页中信息填写完整的价值与意义分析

王达光

【摘要】病案即记录诊断、治疗等信息的文件，作为患者疾病诊断与治疗信息的载体，可以为教学、医疗、科学研究提供重要的依据与素材，代表着医院的治疗水平与医疗质量。病案首页中信息填写完整性直接反映了医院的业务素质与医疗水平，需要及时的发现病案首页信息管理中存在的问题与缺陷，提高医院的医疗数据准确，才能正确的引导医院的管理与发展。本文首先概述了病案首页信息的功能与价值，分析了病案首页中信息填写存在的问题，最后提出了加强病案首页中信息填写完整的措施：加强病案电子信息化管理、加强病案首页环节质量管理、严格执行病案质量检查制度和成立病案首页质量控制三级网络。

【关键词】病案；首页信息；完整性；质量检查制度

Medical record is recorded diagnosis and treatment information file，as a carrier of the disease diagnosis and treatment information can provide important basis and material for teaching，medical，scientific research，represents the level of hospital treatment and medical quality． In the home of medical record information to fill the integrity directly reflects the hospital's service quality and level of medical treatment，the need to timely find problems and defects existed in the home of the medical record information management，improve the hospital medical data is accurate，to correctly guide the hospital management and development． Firstly，this paper introduces the function and value of the home of the medical record information analysis in the home of medical record information to fill in the existing problems，and finally puts forward some strengthening in the home of medical record information to fill in full measure: strengthen the electronic medical record information management，to strengthen medical record homepage link quality management，strict implementation of the medical record quality inspection system and established the home of the medical record quality control of three level network．

【Key words】 Medical record，Home information，Integrity，Quality inspection system

病案是患者在医院就诊治疗的原始记录，反映了患者入院、医嘱、病程记录、检查检验结果、住院、出院、病案编目录入等整个诊疗工作的全过程，是医务人员对患者检查、诊断、治疗、护理等医疗活动生成的资料归档、分析、整理的全面记录［1-2］。病案首页信息由住院医疗信息、患者基本信息、医护人员签名等部分组成，一般情况下病案室在录入病案首页信息时，病案室人员要尊重医师的填写［3-4］。本文具体探讨了病案首页中信息填写完整的价值与意义，现报道如下。

1 病案首页信息的功能与价值

病案首页信息……