我院病案室自1986年1月开始将病案首页信息录入计算机,1992年12月正式运行总部医疗管理软件。经过多年的实践,笔者在微机输入时发现病案首页存在一些问题,现报告如下。1 资料与方法 对我院1996年6月～1997年5月间的出院病案,采取随机抽样的方法抽取500份病案首页进行统计,其中有150份存在缺陷,缺陷率为30％。 In the medical record room of our hospital, the information on the first page of medical records was entered into the computer in January 1986, and the headquarters medical management software was officially launched in December 1992. After years of practice, the author found some problems on the front page of the medical record when the computer was input. The report is as follows. 1 Materials and Methods For the hospital discharge cases from June 1996 to May 1997 in our hospital, we randomly selected 500 medical records from the front page for statistical analysis, of which 150 were flawed and the defect rate was 30%.