摘要
目的对病历书写基本规范中有创诊疗操作定义进行解析,减少临床工作和管理中的困扰。方法分析有创诊疗操作定义的缺陷,提出建议。结果顺利解决争议,消除管理上的困扰。结论有创诊疗操作应该修订为"侵入性、介入性和穿刺诊疗",适合临床工作。
Objective The defects in The Basic Criterion of Documentation of the Medical Record brought trouble to clinical work and management. Methods Through analyzing the defects in definition of invasive diagnosis and treatment,following suggestions were proposed： endoscopy should also be included; records can be completed together with inspection report. Results Disputes and trouble in management were resolved successfully. Conclusion The definition of invasive diagnosis and treatment should be revised as invasive,interventional and puncture diagnosis and treatment,which is suitable for clinical practice.
出处
《中国病案》
2010年第9期13-13,共1页
Chinese Medical Record
关键词
病历书写基本规范
有创诊疗操作
对策
the basic criterion of documentation of the medical record
invasive diagnosis and treatment
countermeasure
