多发伤病历与诊断:专家共识(2023版)  

Chinese expert consensus on medical documentation and diagnosis for multiple trauma(2023 edition)

作　　者：李阳 李辉[2] 陈驾君[3] 许永安[4] 朱凤雪[5] 李占飞[3] 都定元[2] 王天兵[5] 张茂[4] 白祥军[3] 张连阳 国家创伤医学中心 创伤与化学中毒全国重点实验室 中华医学会创伤学分会创伤急救与多发伤学组 中国创伤救治联盟 《创伤外科杂志》编辑委员会 Li Yang;Li Hui;Chen Jiajun;Xu Yongan;Zhu Fengxue;Li Zhanfei;Du Dingyuan;Wang Tianbing;Zhang Mao;Bai Xiangjun;Zhang Lianyang;National Trauma Medical Center;State Key Laboratory of Trauma and Chemical Poisoning;Trauma First Aid and Multiple Trauma Group,Chinese Society of Medicine;China Trauma Alliance;Editorial Board of Journal of Traumatic Surgery(State Key Laboratory of Trauma and Chemical Poisoning,Daping Hospital,Army Medical University,Chongqing 400042,China;Chongqing Emergency Medical Center/Central Hospital Chongqing University,Chongqing 400014,China;National Center for Major Public Health Events,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan 430030,China;The Second Affiliated Hospital of Zhejiang University School of Medicine,Hangzhou 310009,China;Peking University People’s Hospital,Beijing 100044,China;不详)

机构地区：[1]陆军军医大学大坪医院,创伤与化学中毒全国重点实验室,重庆400042 [2]重庆市急救医疗中心/重庆大学附属中心医院,重庆400014 [3]华中科技大学同济医学院附属同济医院/国家重大公共卫生事件医学中心,武汉430030 [4]浙江大学医学院附属第二医院,杭州310009 [5]北京大学人民医院(国家创伤医学中心),北京100044 [6]不详

出　　处：《创伤外科杂志》2023年第8期561-568,共8页Journal of Traumatic Surgery

摘　　要：随着创伤救治体系的完善和技术的普及,我国的多发伤救治得以快速发展。多发伤是创伤中心核心病种,而多发伤的病历书写和诊断仍存在争议。为规范多发伤的病历和诊断,促进创伤救治质量控制体系的建立,现制定《多发伤病历与诊断:专家共识(2023版)》。本共识对多发伤的定义进行了修改,强调了病历首页主要诊断、其他诊断以及手术和操作的填写内容。此外,共识还与相关的规范和分类保持一致,以便于统一认识和学术交流。With the improvement and popularization of trauma care system and related rescue techniques,the management of multiple trauma has rapidly developed in China.Multiple trauma is the core disease in all levels of trauma centers,yet there are still controversies over its medical documentation and diagnosis.In order to standardize this issue and promote the establishment of a quality control system for trauma care,the updated version of Chinese expert consensus on medical documentation and diagnosis for multiple trauma(2023 edition)is released.This consensus has modified the definition of multiple trauma and emphasizes the medical documentation of its primary diagnosis,secondary diagnoses,and surgical procedures in medical records.Additionally,the present consensus keeps consistent with relevant standards and classifications,to facilitate the unified understanding and academic communication.

关 键 词：多发伤 专家共识 病历 诊断 

分 类 号：R641[医药卫生—外科学]