规范介入等诊疗操作记录  

To Standardize Operation Record like Intervention

作　　者：刘玉琦[1] 王军[1] 牛义军[1] 徐志伟[1] 李进[1] 

机构地区：[1]解放军第三○二医院质量管理科,北京市100039

出　　处：《中国病案》2011年第5期4-4,共1页Chinese Medical Record

摘　　要：《病历书写基本规范》对有创诊疗操作记录的书写有明确规定,但对介入等微创诊疗操作记录的书写并未提出明确要求,如果简单要求与有创诊疗操作记录相同似有不妥,经过调研,笔者提出三种具体的解决方案,并详细讨论了每种方案的优点和缺点。There is clear regulation about writing of wounded treatment operation record in Basic Regulations of Medical Record Writing.But it doesn＇t mention clearly about writing of minor-wounded treatment operation record like intervention.It seems not proper to require equally with wounded treatment operation record.After investigation,the author puts forward three concrete solutions,discussing detailed advantages and disadvantages of every solution.

关 键 词：微创诊疗操作记录 书写 规范 

分 类 号：R197.3[医药卫生—卫生事业管理]