重症医学临床查房流程和思维模式  

The Workflow and Thinking Mode of Ward Rounds in Critical Care Medicine

作　　者：付豹 黄伟[2] 傅小云 FU Bao;HUANG Wei;FU Xiao-yun(Department of Critical Medicine,The Affiliated Hospital of Zunyi Medical University,Zunyi 563003,China)

机构地区：[1]遵义医科大学附属医院重症医学科,贵州遵义563003 [2]大连医科大学附属第一医院学科建设与科研管理部,辽宁大连116011

出　　处：《医学与哲学》2022年第8期62-66,共5页Medicine and Philosophy

基　　金：2021年贵州省社会发展领域科技计划项目(黔科合支撑[2021]一般083)。

摘　　要：重症医学作为二级学科成立才10余年,与普通科室不同,重症医学科收治的患者都处于极其危重状态,需要在查房过程中迅速做出诊断、制定治疗决策并高效执行。重症医学临床查房应充分做好查房前准备,简洁汇报病史,运用核查表行结构化查房,组织好多学科查房,注重人文关怀。重症医学查房的临床思维包括:抓住主要矛盾、注重整体,诊断第一、治疗规范,运用连续“提问”和连续“假设”的证伪思维,动态地收集患者信息,不断巩固自己的诊断,或者及时修正自己的诊断和补充自己的诊断,从而让患者得到最优的治疗。Critical care medicine has only been established as a second-level discipline for more than 10 years.Unlike general departments, all patients in the department of critical care medicine are all in extremely critical condition, requiring rapid diagnosis, quick medical decision-making and efficient execution during ward rounds. Clinical ward rounds in critical care medicine should be fully prepared, with concise report, using checklists to conduct structured rounds, organizing multi-disciplinary ward rounds, and paying attention to humanistic care. The clinical thinking in ward rounds of critical care medicine refers to principal-contradiction-focused mode, viewing the diagnosis as a whole, diagnosis priority, standardized treatment, adopting continuous "questioning" and continuous "hypothesis", dynamically collecting patient’s information, constantly perfecting one’s own diagnosis by correcting and supplementing one’s own diagnosis in time, so as to provide the optimal treatment for patients.

关 键 词：重症医学 查房 临床思维 

分 类 号：R-05[医药卫生]