创伤外科病历书写存在的问题及改进建议  

Existing problems and suggestions for medical record writing in trauma surgery

作　　者：刘朝普 李辉[1] 黄光斌 都定元 Liu Chaopu;Li Hui;Huang Guangbin;Du Dingyuan(Department of Trauma Surgery,Central Hospital of Chongqing University,Chongqing Emergency Medical Center,Chongqing 400014,China)

机构地区：[1]重庆大学附属中心医院,重庆市急救医疗中心创伤外科,重庆400014

出　　处：《中华创伤杂志》2023年第11期974-979,共6页Chinese Journal of Trauma

基　　金：国家创伤区域医疗中心(委市共建)重大研究项目(jjzx2021⁃gjcsqyylzx01);重庆英才计划研究项目(cstc2022ycjh⁃bgzxm0245)。

摘　　要：创伤外科的病历书写与传统外科存在区别。创伤外科病历记录了创伤救治的医疗全过程,反映创伤技术水平及救治效果。目前,创伤外科病历书写大多沿用传统外科各专业的书写模式,不能反映创伤患者整体损伤情况及诊断治疗经过,导致创伤外科病历质量参差不齐,妨碍创伤救治与学术交流。创伤评估有其特殊性,传统体格检查方法并不完全适用于创伤患者。此外,随着诊疗技术的进步,临床评估过程中也可以避免采用一些导致疼痛、延误抢救,甚至造成损伤的查体方法和诊疗操作。随着创伤救治理论技术和学科发展,创伤外科病历的书写有待进一步规范和统一。笔者通过分析创伤外科病历书写的特殊性,梳理和总结目前病历书写中存在的问题并提出改进建议,为规范创伤外科病历书写、提升创伤救治综合实力提供参考。Medical record writing in trauma surgery differs from that of conventional surgery.The medical records in trauma surgery encompass the entire process of trauma management,serving as an indication of expertise in trauma management and treatment effectiveness.At present,most medical records in trauma surgery are written in the conventional writing mode of various surgical specialties,which fails to indicate the overall injury situation of trauma patients and the process of diagnosis and treatment,resulting in unevenly qualified medical records in trauma surgery,which hinders trauma treatment and academic exchange.Given that trauma assessment owns unique nuances,conventional physical examination methods are not entirely applicable to trauma patients.Moreover,with the advancement of diagnostic and therapeutic technologies,certain physical examination techniques and medical procedures that may induce pain,impede timely rescue,or even cause injury can be circumvented in clinical assessment.As theories,techniques,and disciplines in trauma care continue to develop,there arises a need for further standardization and uniformity in medical record writing in trauma surgery.By analyzing the special characteristics of medical record writing in trauma surgery,the authors sorted out and summarized the problems in medical record writing and put forward suggestions on improvement of medical records in trauma surgery to provide reference for standardization of medical record writing in trauma surgery and improvement of the comprehensive strength of trauma treatment.

关 键 词：创伤与损伤 多处创伤 创伤诊治中心 病史记录 质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]