住院病案首页数据是国家卫计委考核三级综合医院的重要内容.因此,对于三级综合医院来说,如何规范数据产生流程,保证上传数据质量已成为摆在他们面前的重要课题.文章通过作者在某三甲医院复审中的实践,初步探讨了相关思路和方法,包括对原卫生部2012版住院病案首页的修订、住院病案首页的计算机智能化逻辑校验、对医师ICD-10知识的宣教培训及信息的公示和反馈;文章还就国家卫计委的相关考核标准展开思考和讨论.坚持标准、拓展思路、持续改进,期待该院的经验能对同类医院产生些微借鉴作用.%The data in the front pages of hospitalized medical records is the important part of a Grade Three Comprehensive Hospital in the assessment announced by the National Health Development Planning Commission. Therefore, how to standardize the process of data generation and guarantee the quality of the data have become important problems for them. Through the practice in the review process of a Three A and Tertiary Hospital, the author investigated related thoughts and methods, which included the revise of the front pages in medical records of 2012 edition announced by the Ministry of Health, the intelligent logic check of the front pages in hospitalized medical records, as well as the education training, publication of the information and feedback of the doctors to knowledge of ICD-10. And it also discussed the related inspection standard of the National Health Development Planning Commission. We should keep adhere to the standards, expand ideas and make continuous improvement, and also look forward to the experience could make some reference function to the similar grade hospitals.
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