放射科医疗文书书写规范的思考  

Reflection on the writing standards of medical documents in radiology department

作　　者：陈国平[1] 张景峰 戴琦 闫昆[1] 章维[2] 张宏彬[1] 郭丽萍 郑建军[1] Chen Guoping;Zhang Jingfeng;Dai Qi;Yan Kun;Zhang Wei;Zhang Hongbin;Guo Liping;Zheng Jianjun(Department of Radiology,Ningbo No.2 Hospital,Ningbo 315010,Zhejiang,China;Department of Science and Education,Ningbo No.2 Hospital,Ningbo 315010,Zhejiang,China)

机构地区：[1]宁波市第二医院放射科,浙江宁波315010 [2]宁波市第二医院科教部,浙江宁波315010

出　　处：《中国毕业后医学教育》2023年第6期433-437,共5页Chinese Journal of Graduate Medical Education

基　　金：浙江省医药卫生科技计划项目(2022KY1136);教育部产学合作协同育人项目(221004618022023);2022年度校级本科教学改革创新重点项目(FYJG202201);“华美”医学教育研究基金(2021HMJYZD01、2021HMJYZD02);宁波市影像医学临床医学研究中心项目(2021L003);宁波市省市共建医学重点学科-医学影像学项目(2022-S02)。

摘　　要：放射科医疗文书作为临床病历的重要组成部分,不仅可以为临床诊疗决策提供循证依据,还有助于规避某些医疗风险。放射科医疗文书主要包括放射科诊断文书、放射科操作文书和放射科告知文书。目前不同地域或不同医院之间放射科医疗文书的差异较大、质量参差不齐,而且存在时间滞后、信息错误、缺乏规范和价值不足等问题。因此,加强放射科医疗文书的书写规范尤为重要,不仅有助于持续改进放射科临床医疗质量、提升住院医师的临床诊断思维能力,而且有助于临床研究素材的规范积累,为推进放射科医、教、研协同发展奠定基础。As an important part of clinical medical records, radiology medical documents may not only provide evidence for clinical diagnosis and treatment decisions, but also be helpful to avoid certain medical risks. Medical documents of radiology department mainly include diagnostic documents, operation documents and informed consent. At present, there are large differences of radiology medical documents between different regions or different hospitals. And the quality of radiology medical documents is uneven between different regions or different hospitals. There are also problems such as time delay, information errors, lack of standards and limited value. Therefore, it is significantly important to emphasize and comply with the writing standards of medical documents in radiology department. It will help to continuously improve the quality of clinical medical activities and enhance the thinking ability of clinical diagnosis of residents. And it may accelerate the accumulation of the standardized clinical research materials. At last it will promotes the coordinated development of medicine, teaching and research in the department of radiology.

关 键 词：放射科 医疗文书 住院医师规范化培训 

分 类 号：G40-034[文化科学—教育学原理] R445[文化科学—教育学]