随着临床肺功能检查的广泛应用,检查项目逐步增多,对肺功能报告的要求越来越高。特别是对肺部疾病的功能分级诊断和围手术期风险评估意义重大,涉及临床各科室,有些医院胸腹部手术和其他重大手术肺功能被纳入临床路径,由于大部分非呼吸专业的临床医生对肺功能报告的解读依赖于肺功能诊断医生的书写报告,肺功能结果是通过报告的形式表现出来,反映出所有的检查内容、质量控制、诊疗标准、专业知识背景及进一步的诊疗建议等信息,一份合格的肺功能报告可以从多层面诠释呼吸疾病的病理生理改变,帮助临床对呼吸疾病的诊断与鉴别诊断、疗效评价、风险评估、估计预后提供准确信息。但在我们的实际工作中关于肺功能结果判断标准存在认识上的差异,缺乏规范化的标准,加之肺功能检查仪型号各异,检查项目不同,因此在书写肺功能诊断报告时难免存在多个版本,出现地域之间和各医院之间诊断标准不统一、随意性、个性化等问题,在不同的医院或不同的肺功能检查室相同的检查结果,不同的诊断结论的事件频出,不利于医疗风险的控制,与当今现代医学发展和规范化管理的模式不相适应。针对肺功能书写过程中存在的问题,如:书写格式、内容、措辞、随意性等,依据肺功能诊断分级标准及COPD肺功能诊断标准,研发创建了电子版《M.H肺功能诊断应用软件》系统,获国家计算机软件著作权。经过一年的试用其性能稳定、资料电子存档便于查询、功能可扩展、可与医院网络系统对接。规范了本实验室肺功能诊断报告,提高了肺功能诊断水平,同时也利于质量控制、进修带教、培训考核等工作。 With the wide application of clinical pulmonary function tests, the number of examination items is gradually increasing, and the requirements for reporting lung function are getting higher and higher. Especially for functional classification of lung disease and perioperative risk assessment of great significance, involving various clinical departments, some hospitals, thoracoabdominal surgery and other major surgical lung function is included in the clinical pathway, as most non-respiratory professional clinicians The interpretation of the pulmonary function report relies on the writing report of the pulmonary function diagnosis doctor. The result of the pulmonary function is reported through the report, which reflects all the contents of the examination, quality control, medical standards, background of professional knowledge and further diagnosis and treatment, A qualified pulmonary function report can interpret the pathophysiological changes of respiratory diseases from multiple perspectives, and help to provide accurate information on clinical diagnosis and differential diagnosis of respiratory diseases, evaluation of efficacy, risk assessment and estimation of prognosis. However, in our practical work, there are differences in the judgment criteria of lung function results, the lack of standardized criteria, and the different types of lung function test instruments and the different examination items. Therefore, it is inevitable that there are multiple versions of lung function diagnosis reports , There are regional and between the hospitals diagnostic criteria are not uniform, arbitrary, personalized and other issues in different hospitals or different pulmonary function examination room the same test results, different diagnostic findings of frequent incidents, is not conducive to The control of medical risks is incompatible with the development and standardization management of modern medicine today. According to the pulmonary function diagnosis and grading standards and pulmonary function diagnostic criteria of COPD, R & D and creation of the electronic version of “MH pulmonary function diagnostic software” system for the problems in the process of writing pulmonary function, such as: writing format, content, wording, , Won the national computer software copyright. After a year of trial of its stable performance, easy to query data archiving, scalable functionality, docking with the hospital network system. Standardize the laboratory pulmonary function diagnosis report, improve the level of pulmonary function diagnosis, but also conducive to quality control, further education, training and examination work.