病案首页在医院的医疗、病案、统计和医院管理工作中使用了10年左右,是我国病案内容组成中的一个标准性文件,其内容格式基本满足了病案、统计、临床工作的需要。随着我国医疗事业的发展,医疗付费形式的改变,医院管理、人才培养方式的改革,控制平均住院费用的管理需求,病案首页中的部分内容已不适应医疗改革的现状。需要在原有的基础上进行修正、补充,使其更加合理,既要达到医院管理的目的,又要达到病案信息管理、疾病分类、统计的要求,更需便利病案首页在医疗机制、费用改革 Medical records, medical records, statistics, and hospital management work in the hospital have been used for about 10 years on the front page of the medical record. It is a standard document in the composition of medical records in China, and its content format basically meets the needs of medical records, statistics, and clinical work. With the development of China’s medical industry, the change in the form of medical payment, the reform of hospital management and personnel training methods, and the need to control the average cost of hospitalization, some of the content on the front page of medical records has not adapted to the current status of medical reform. It is necessary to make amendments and supplements on the basis of the original to make it more reasonable. It is necessary to achieve the purpose of hospital management, but also to meet the requirements of medical record information management, disease classification, and statistics, and it is even more necessary to facilitate the reform of the medical system and cost of the medical record.