我们自1985年起对本科资料进行了规范化和系统化管理,在信息引进、病历积累、经验总结及资料检索等方面开展了一些工作,现将初步体会总结如下: 资料管理内容 一、一般性资料 1.病历随访卡:主要记录病人原始资料,将病人发病经过、主要临床表现和特殊体征、影象学所见及手术名称、治疗结果等主要项目记录在案。 Since 1985, we have conducted standardized and systematic management of undergraduate information. We have carried out some work in the areas of information introduction, medical record accumulation, experience summarization, and data retrieval. We will now summarize our preliminary understanding as follows: Data Management Contents I. General Information 1. Medical history follow-up card: The main record of the patient’s original data, the patient’s onset, the main clinical manifestations and special signs, imaging findings and surgical name, treatment results and other major projects recorded.