目前,对统一病案首页中“诊断符合情况”一栏的判断结论(符合、不符合、无对照)尚无相应的操作标准。这无论在管理的完善性、操作的规范性以及信息质量保障方面都有缺陷,也一直使临床医生甚感困惑。因此,笔者建议尽快制定相应的操作标准。理由如下:①笔者查阅了新近出版的有关病案管理的教课书、教材、工具书.均无此内容,唯《医疗护理技术操作常规》(楼方岑主编.第3版.北京:人民军医出版 At present, there is no corresponding operating standard for the judgment conclusion (conformity, non-conformity, no control) in the “Diagnosis Conformity” column in the first page of the unified medical record. This is flawed in terms of the perfection of management, the standardization of operations, and the protection of information quality, and it has always puzzled clinicians. Therefore, the author proposes to formulate corresponding operating standards as soon as possible. The reasons are as follows: 1 The author reviewed the recently published textbooks, textbooks, and reference books related to medical record management. There is no such content, but the “medical care technology operating practices” (Fang Fanglu editor. 3rd edition. Beijing: People’s Military Medical publishing