| 有创诊疗操作定义的缺陷及对策 |
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| 引用本文： | 叶昌雄,周洪波.有创诊疗操作定义的缺陷及对策[J].中国病案,2010,11(9):13-13. |
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| 作者姓名： | 叶昌雄 周洪波 |
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| 作者单位： | 广州南方医科大学南方医院,广州市,510515 |
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| 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。
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| 关 键 词： | 病历书写基本规范 有创诊疗操作 对策 |
Defeats of Definition of Invasive Diagnosis and Treatment and Its Countermeasures |
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| Ye Changxiong,Zhou Hongbo.Defeats of Definition of Invasive Diagnosis and Treatment and Its Countermeasures[J].Chinese Medical Record,2010,11(9):13-13. |
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| Authors: | Ye Changxiong Zhou Hongbo |
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| Institution: | ,Nanfang Hospital Affiliated Southern Medical University,Guangzhou 510515,Guangdong Province,China |
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| Abstract: | 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. |
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| Keywords: | the basic criterion of documentation of the medical record invasive diagnosis and treatment countermeasure |
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