摘要
病案首页是医院管理、信息统计、临床研究的重要数据来源,也是反映医疗质量、业务水平、质控管理的综合内容。当病人涉及工伤理赔、交通事故、伤残鉴定、医疗纠纷时,病案首页内容记录是事实依据,更是判断法律责任的重要证据性文件。提高病案首页质量,不仅是为医院提高医疗安全与质控管理,更是为今后DRGs付费制度,为智慧医疗,为未来大数据提供信息支持。
Medical record homepage is important data source for hospital management,information statistics,and clinical research,and comprehensive content reflecting medical quality,business level,and quality control management.When a patient is involved in work-related injury claims,traffic accidents,disability identification,or medical disputes,homepage of medical record is factual basis,and important evidence document to judge legal responsibility.Improving quality of medical record homepage can improve medical safety and quality control management of the hospital,and provide information support for future DRGs payment system,smart medical care,and future big data.
作者
楼丹君
LOU Dan-jun(Hangzhou Zhan's Traditional Chinese Medicine Orthopedics Hospital,Hangzhou,Zhejiang 310015)
出处
《智慧健康》
2020年第12期173-174,共2页
Smart Healthcare
关键词
病案首页
缺陷原因分析
改进措施
Medical record homepage
Analysis of defects causes
Improvement measures
