医师应正确书写手术操作名称

Physicians Should Write Operation Names Correctly

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。

Objective To take full advantage of the value of medical records,physicians should correctly write operation names in the writing of medical records. Methods Operation names in the first page of medical records were written irregularly in the process of list and categories. Results A considerable number of terms can not accurately reflect the actual situation of operation,with confused operation terms. Conclusion Physicians should write operation names correctly and regularly in accordance with international classification of procedures to provide more correct information for retrieval of classified management of operation,access systems,clinical pathway,health care payment etc.