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目的设计科学合理的病案首页信息系统,提高病案统计质量。方法通过标准字典库提供规范性诊断,通过信息共享、自动生成、在线控制等功能减少录入环节。结果应用信息化的病案首页,可以提高病案首页填写质量,确保各类统计报表数据的真实性、准确性、可靠性。结论应用病案首页信息系统,不仅减少病案统计人员的重复劳动和人力物力的浪费,提高工作效率和工作质量,而且,还能从根本上降低病案首页缺陷的发生率。
Objective To design a scientific and reasonable case information home information system to improve the quality of medical records statistics. The method provides normative diagnosis through the standard dictionary library, and reduces the inputting links through the functions of information sharing, automatic generation and on-line control. Results The application of information on the first page of the medical record can improve the quality of the first page of the medical record and ensure the authenticity, accuracy and reliability of all kinds of statistical report data. Conclusion The application of medical information home page information system not only reduces duplication of work and manpower and material resources of medical record statisticians, improves work efficiency and quality, but also fundamentally reduces the incidence of the first page of medical records.