住院医规范书写病理诊断报告的培训  

Training for Resident of Pathology to Standardize Pathological Report Writing

作　　者：金木兰[1] 蒋镭[1] 

机构地区：[1]首都医科大学附属北京朝阳医院病理科

出　　处：《中国病案》2012年第7期61-62,共2页Chinese Medical Record

摘　　要：病理诊断报告是重要的医疗记录,在对病理住院医师进行培训时应力求做到病理诊断报告的规范化。文章根据在日本接受的病理诊断培训、结合病理经典教材、病理操作规范及日常工作经验,提出规范化病理诊断报告应包括的内容以及注意事项,特别强调了注明术式的必要性以及不同标本类型报告内容的区别。Pathological diagnosis report is a vital medical document, which needsto be standardization when having training for pathological resi- dents. According to pathological diagnosis training in Japan with combining classic pathological teaching materials, pathological operation regulations and daily work experience, the author puts forward content and points for attention that should be included in standard pathological diagnosis report should include, in which it specially emphasizes the necessity of marking out mode of operation and the difference among different specimen report content.

关 键 词：病理报告 规范化 住院医培训 

分 类 号：R197.3[医药卫生—卫生事业管理]