CAJ | 학술논문

病案首页作为病案信息最为集成的一部分，要求每一份首页都必须高质量的完成。本文通过病案管理员录入首页信息、统计核查软件及病案复印总结首页填写中易出现的-10疾病编码及漏、错填信息等问题，并提出针对性的措施，增加各部门首页重要性意识，结合相关知识培训及信息化等手段，提高病案首页填写质量，提升医院医疗管理水平。
병안수혈작위병안신식최위집성적일부분，요구매일빈수혈도필수고질량적완성。본문통과병안관리원록입수혈신식、통계핵사연건급병안복인총결수혈전사중역출현적-10질병편마급루、착전신식등문제，병제출침대성적조시，증가각부문수혈중요성의식，결합상관지식배훈급신식화등수단，제고병안수혈전사질량，제승의원의료관리수평。
As the one of the most integrated part of the medical record information,each Medical Record Front-page must be required to be completed by high quality.We summarized the problems,such as the ICD-10 disease coding,the omissions and the wrong information and other issues,existing in the fil ing of Medical Record Front-page,by the way of fil ing the Medical Record Front-page by medical records administrators,statistical verification software and medical record copying.We proposed specific measures to solve the problem.We must increase awareness of the importance of Medical Record Front-page.We must use the knowledge training and information technology to improve the quality of the fil ing of Medical Record Front-page and enhance the medical management level.