《病历书写基本规范》对有创诊疗操作记录的书写有明确规定,但对介入等微创诊疗操作记录的书写并未提出明确要求,如果简单要求与有创诊疗操作记录相同似有不妥,经过调研,笔者提出三种具体的解决方案,并详细讨论了每种方案的优点和缺点。 Although the basic norms of medical record writing clearly stipulate the writing of an invasive diagnosis and treatment record, there is no explicit requirement on the intervention such as the record of minimally invasive diagnosis and treatment. If the simple requirement is similar to the record of an invasive diagnosis and treatment operation, After research, I propose three specific solutions, and discussed in detail the advantages and disadvantages of each program.