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目的为了充分利用病案具有的价值,在病历书写过程中医师应正确书写手术操作名称。方法列举分类过程中发现医师在病案首页手术操作栏内不规范填写的手术操作名称。结果有相当数量的术语不能准确反映手术操作的实际情况,手术栏用语混乱。结论正确规范书写手术操作名称需要医师认真参照国际手术操作分类书写,为手术分级管理、准入制度、临床路径、医疗付款等资料的检索提供更为准确数据。
Purpose In order to make full use of the value of the medical record, the physician should correctly write the name of the operation during the medical record writing. Methods listed in the classification process found that physicians in the medical records on the first page of the surgical operation of non-standard name of the operation. The results of a considerable number of terms can not accurately reflect the actual operation of the surgical situation, surgical column confusion terms. Conclusions Correctly regulating the name of writing operation requires doctors to conscientiously refer to the classification of international surgical operations to provide more accurate data for the retrieval of data such as operation classification management, admission system, clinical pathway and medical payment.