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病案首页是医院医疗统计最基本的数据,《中华人民共和国统计法》第二条规定:“统计的基本任务是对国民经济和社会发展情况进行统计调查、统计分析,提供统计资料和统计咨询意见,实行统计监督。”数据不准确为上级卫生行政部门了解和掌握居民的医疗需求,医疗服务情况,编制区域医疗规划与卫生事业发展计划,评价医疗服务的社会效益和经济效益,对领导部门决策、与世界各国的资料交流等都会产生不良影响。所以病案首页的准确填写很重要,要认真、如实、规范才能真正反映实际情况。现就常见不规范或填写不准确的主要情况列出如下:
The top of the medical record is the most basic data of hospital medical statistics. Article 2 of the “Statistical Law of the People’s Republic of China” stipulates: “The basic task of statistics is to conduct statistical surveys, statistical analyses, provide statistical data, and provide statistical advisory opinions on the national economy and social development. The implementation of statistical supervision.” The inaccuracy of data is that the superior health administrative department understands and grasps the residents’ medical needs and medical service conditions, compiles the regional medical plan and the development plan of the health service, evaluates the social and economic benefits of the medical service, and makes decisions for the leaders. , and the exchange of information with other countries around the world will have adverse effects. Therefore, it is very important to fill out the first page of the medical record accurately. It is necessary to be serious, truthful, and standardized in order to truly reflect the actual situation. The following are the major cases of common non-standard or inaccurate completion: