Abstract：Objective To review the filling quality of the first page of electronic medical records,and to analyze the reasons for defects and put forward corrective measures.Methods A total of 19 974 pieces of the first page of medical records of the patients who were discharged from January 2017 to March 2018 were retrieved from the electronic medical records.The filling quality of the basic information,diagnosis information,surgery information and other information in the first page were reviewed respectively and analyzed by classification.Results The defect rate of the first page of medical records was 2.34%.The defect mainly focused on the basic information (56.33%),and the defect rate of hospitalization information,diagnosis information,accordance and surgery information was 12.09%,14.08%,2.56%and 14.94%respectively.Conclusion The filling defects of the first page of electronic medical records in our hospital are more.
杨燕媚. 基于电子病历的病案首页填写质量分析[J]. 中国当代医药, 2018, 25(9): 133-135.
YANG Yan-mei. Analysis of filling quality on the first page of medical records based on electronic medical records. 中国当代医药, 2018, 25(9): 133-135.
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