The Problems and Improvement Measures of The First Page of Medical Record

Abstract

Objective According to the Ministry of Health requirements in our hospital in 2012 to replace the new medical record,to explore new medical record fill out the problems and countermeasures,and continuously improve the new medical record collection quality,make the home better information service of medical statistics,clinical research,medical quality assessment,and medical accident identification field.Methods The first page of medical records was feedback window of medical record information and the original data of statistics,medical quality,medical record quality inspection and evaluation of medical treatment quality was the quality control of medical records,the problem was feedback to the issue department for improvement.Results The medical record information was crucial,the new medical record was more in line with theStatistics Law,the hospital management,and the international classification of diseases ICD-10 requirements,specification writing medical record was to be imperative.Conclusion Through the strengthening of medical record quality in training,so that all physicians recognized the importance of carefully fill in the first page of medical records and the responsibility to the work attitude,so that the medical record quality was enhanced to ensure accurate statistical data.

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