摘要
根据前卫生部《病案首页部分项目填写说明》和《重庆三峡中心医院质量评分标准(2011年)》,对2015年5月份的部分病案首页进行检查,结果是病案首页填写信息缺项、错项和书写不规范事件较多。其根本原因是医院管理层对病案首页质量不重视,有制度未落实,导致病案首页出现问题。需要采取相应措施对这种现象进行实施控制。
According to the former Ministry of Health,＂the medical record to fill in part of the project description＂and ＂Chongqing Three Gorges Central Hospital Quality Grading（2011）＂,on part of the medical record checks in May 2015,the problem is that the medical record information to fill in missing items,wrong items and writing non-standard situations. The fundamental reason is that hospital management does not attach importance to the quality of the medical record,there is not a system implemented,resulting in many problems at the medical record. The need is to take appropriate measures to control this phenomenon.
出处
《中国卫生标准管理》
2015年第32期2-3,共2页
China Health Standard Management
关键词
病案首页
医疗信息
缺陷
措施
First page of medical record
Medical information
Defect
Measures
