Complete medical record of the existing problems and countermeasures_0.docVIP

 PAGE \* MERGEFORMAT 12 Complete medical record of the existing problems and countermeasures OF: Blow letters were super, Ni Jing, Li Yunming, Sun Na [Keywords:] of the medical record; problem; Strategy Medical record is the medical staff during the course of medical treatment activities of a comprehensive record of the situation. The medical record is the medical record information but concise summary of the rich is the main source of medical information, it concentrates the most important of the entire contents of medical records [1]. It provides the basic situation of the patient, diagnosis, surgery, emergency treatment, diagnosis, prognosis, fees and other basic information, so fill in the quality of the medical record medical information direct impact on the authenticity, but also objectively reflect the level of medical quality. General Logistics Department of Health 09 edition of the medical record of patient information into basic information, diagnostic information, operation information, other information of four parts, this article in our hospital from 1 March 2010 filled in the medical record analysis of the problems, and for put forward corresponding countermeasures. Problem Analysis 1 1.1 Basic Information Bar Problems 1.1.1 completed by the out-patient registry errors include the basic information fill in the names wrong, completely wrong homonym different word or name; date of birth entry errors caused by age and actual access to large; marital status, occupation of incorrectly; ID Most are not complete; work unit and address of the often write “None”, Statements of Account / permanent address in the failure to fill in the actual situation. 1.1.2 doctor to fill out the increase in new home health payment fees do not correspond to, or correspondence to grasp whether or not accurate according to the specified completed military training injuries, such as the army did not hurt the sick and wounded military training and external