In order to further standardize the writing of traditional Chinese medicine medical records in hospitals and strengthen the data quality management on the homepage of medical records, on the afternoon of February 24, Xuecheng Hospital of Traditional Chinese Medicine organized a training session on writing traditional Chinese medicine medical records and standardizing the homepage of inpatient medical records. Li Yuxiao, deputy head of the medical department, presided over the meeting, and quality controllers from various clinical departments attended the meeting.
At the meeting, the spirit of the 2021 secondary public hospital performance appraisal medical record homepage quality control work video training session was conveyed, learning The “Basic Standard for Writing and Management of Medical Records of Traditional Chinese Medicine in Shandong Province (2021 Edition)”, combined with the actual situation of filling in the first page of medical records in hospitals, explained the specific requirements for filling in the first page of medical records, and analyzed the standardized filling of the contents of the first page of medical records. The problem items were explained in detail, so that the quality controllers present had a better understanding of the requirements for filling out the first page of the medical record.
The homepage of the medical record is a comprehensive reflection of the medical record information. It condenses the most important content of the entire inpatient medical record and is an important original basis for medical treatment, medical statistics, hospital management and clinical medical research.
Through this training, it not only further standardizes the writing of TCM medical records, but also enables each clinical department to further clarify the requirements for filling out the first page of medical records and the specific filling standards, which are helpful for standardizing clinical medical behavior, ensuring medical safety, maintaining The legitimate rights and interests of patients are of great significance.