创面修复科病史采集全国专家共识(2021年版)

National expert consensus on medical history collection in wound repair department(2021 version)

病史采集主要是由临床医师通过系统问诊获取临床资料,结合体格检查、实验室及器械检查等从而完成患者入院记录及门诊病历书写。目前临床普遍存在病历内容记录不完整、不规范,病历收集不及时、图片资料缺失及质量不高、无法与国际接轨等情况。为提升创面修复科的病史采集规范化水平,专家组根据国内目前病历收集情况,结合国内外报道,从病史信息采集表格化、创面拍摄方面进行阐述,探讨如何在病史采集过程中和患者参与模式下提高临床医师的工作效率和病历质量,并减少医疗隐患。

Medical history collection usually refers to the process of obtaining clinical data from systematic inquiry carried out by clinicians,combined with physical,laboratory and equipment examinations to complete the admission records and outpatient medical records.At present,there are many problems in medical records,such as incomplete and non-standard records of medical records,untimely collection of medical records,lack of pictures and data of low quality,and failure to meet international standards.In order to improve the standard level of history collection in wound repair department,based on the current collection of medical records in China and combined with domestic and foreign reports,the expert group elaborates from the aspects of tabular collection of medical history information and wound shooting,to explore how to improve the clinician′s work efficiency and medical record quality,and reduce medical hidden trouble in the process of medical history collection and patient participation mode.