多发伤病历与诊断：专家共识意见（2013版）

多发伤病历书写争议颇多,国际疾病分类（ICD）一10不能满足其诊断要求。本文系统阐述了多发伤病历书写要点,提出其诊断包括损伤诊断、损伤并发症诊断和并存疾病诊断三部分,损伤诊断排列应遵循由上而下、从内向外、先重后轻及左右前后的原则。

Consensus on medical documentation and diagnosis of multiple injury

There are many disputes on the writing of clinical record for multiple injury, and the ICD-IO couldn＇t be qualified for the diagnosing requirement of multiple injury. In this paper, the main points of clinical re- cord writing for multiple injury were initially elucidated systematically. It was believed that the diagnosis of multiple injury should include diagnosis of injury, diagnosis of injury complications and diagnosis of concomitance diseases, and the disposition of diagnosis in the clinical record should follow the sequence of head-toe,inside-outside and se- vere-slight.