日间手术病历书写与管理专家共识(2024版)

Expert consensus on the writing and management of day surgery medical records(2024 edition)

随着公立医院高质量发展的需要,日间手术占择期手术比例持续增长。日间手术模式改变了传统住院手术服务流程,对医疗质量管理提出了更高的要求,医疗机构需建立相应的日间手术病历书写管理制度。但目前尚缺乏统一的日间手术病历书写规范和标准。为进一步规范医务人员日间手术病历书写,提高医疗机构的日间手术病历管理水平,国家卫生健康委医院管理研究所牵头组织专家编写本共识,从我国医疗机构日间手术病历书写现状及存在的问题、日间手术病历书写内容及要求、病历管理等方面进行详细阐述,以期为我国各级医疗机构日间手术病历书写提供参考模板。

With the high-quality development of public hospitals,the proportion of day surgery to elective surgery continues to increase.The day surgery mode has changed the traditional inpatient surgery service process,and put forward higher requirements to medical quality management.Medical institutions need to establish a suitable management system for day surgery medical record writing.However,there is still a lack of unified norms and standards for day surgery medical record writing at the national level.In order to further standardize the writing of day surgery medical records by medical personnel and improve the management level of day surgery medical recordsin medical institutions,the National Institute of Hospital Administration,National Health Commission organized experts to write this consensus.It elaborated in detail on the current situation and existing problems of day surgery medical record writing in medical institutions in China,the content and requirements of day surgery medical record writing,and the management of medical record,in order to provide a reference template for the writing of day surgery medical records in medical institutions at all levels.