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为了使医学信息标准化、程序化、规范化,总后卫生部于1992年修订的《病案首页》和全军统一的医疗信息管理软件,已经运行实践了近七年,对医学统计起到了科学、准确、有效的积极作用,随着医学信息的飞速发展,根据当前卫生系统的实际需要,在第四版《医疗护理技术操作常规》中将病案首页中项目又进一步完善,原首页项目基础上又增加了不少新的项目。我院于1999年10月1日正式启用新版病案首页,为使各科室准确填写《病案首页》现将新版《病案首页》填写做如下要求说明:
In order to standardize, program, and standardize medical information, the Medical Records Management Software revised by the Ministry of Health in 1992 and the unified medical information management software of the entire military have been in operation for nearly seven years, and have played a scientific and accurate role in medical statistics. With the rapid development of medical information, according to the actual needs of the current health system, in the fourth edition of “Medical Care Technology Operation Practices”, the project in the first page of the medical record has been further improved, and the original first-home project has been increased. A lot of new projects. Our hospital officially opened the new medical record homepage on October 1st, 1999. In order for each department to fill in the “Home of Medical Record” accurately, the following new requirements for the “First Record of the Medical Record” are explained as follows: