用图文手术记录能提高医疗服务品质  

Using pictorial operative records to improve the quality of medical services

作　　者：徐向华[1,2] 卢强[1,2] 刘学民[1,2] 李建辉[3] 汤博[4] 马锋[4] 史爱华[4] 吕毅[1] 

机构地区：[1]西安交通大学先进外科技术与工程研究所,陕西西安710061 [2]西安交通大学第一附属医院肝胆外科,陕西西安710061 [3]西安交通大学先进外科技术与工程研究所 陕西省人民医院肿瘤外科,陕西西安710068 [4]西安交通大学先进外科技术与工程研究所

出　　处：《医院与医学》2015年第2期19-22,共4页Hospital and Medicine

基　　金：国家自然科学基金科学仪器专项（81127005）

摘　　要：医院信息化建设的发展，传统手术记录成为医院全面信息化的“死角”，单一文字手术记录方式无法满足外科多学科诊疗模式诊治（MDT）的需求。患者及家属难以理解手术记录成为造成医患矛盾的隐患，为解决以上问题，我们提出图文手术记录系统及符合我国医疗环境的规范，借助不断发展成熟的计算机技术和摄影设备，制作图文并茂的外科手术记录，促进医院信息化建设，让患者及家属更加直观的了解手术过程，消除其疑惑，减少医患矛盾的发生，提高医疗服务品质。Traditional operative records have become a problem in the development of hospital information systems. Operative records which only use words cannot meet the needs of diagnosis and treatment in a multi-disciplinary team （MDT）. Patients and their families have difficulty understanding the operative records, and it is easy to create conflict between doctor and patient. To solve these problems, we present a pictorial operative record system that adapts to the Chinese medical system through advanced computer technology and camera equipment to make illustrated surgical records. Patients and their families can understand the operation process by pictorial operative records better than traditional operative records, eliminate their doubts, reduce the incidence of doctor-patient conflicts and improve the quality of medical services.

关 键 词：图文手术记录 医患关系 改善 

分 类 号：R197.3[医药卫生—卫生事业管理]