摘要
近年来,我国创伤中心事业蓬勃发展,显著改善了多发伤的救治质量。随着DRG分组付费和新病案首页编写要求等政策的出现,多发伤病历的书写和诊断出现一些新问题。为更好地指导多发伤病历书写与诊断,国家创伤医学中心专家委员会、中华医学会创伤学分会创伤急救与多发伤学组、中国创伤救治联盟和《创伤外科杂志》编辑委员会共同牵头,由具有丰富多发伤救治经验的专家组成共识编写团队联合发布了《多发伤病历与诊断:专家共识意见(2023版)》(以下简称“共识2023版”)。本文介绍了共识2023版的基本情况,详细解读了共识2023版中对多发伤定义和分型的解释以及多发伤病历诊断书写过程中的要求,供创伤救治医务人员参考。
In recent years,the trauma center establishment in China has flourished,significantly improving the quality of treatment for multiple trauma.With the introduction of policies such as Diagnosis Related Group(DRG)payment system and new requirements for writing medical records,there have been new issues arising in the medical documentation and diagnosis of multiple trauma.In order to provide better guidance for the medical documentation and diagnosis of multiple trauma,the National Trauma Medical Center Expert Committee,the Trauma Emergency and Multiple Injury Study Group of the Chinese Medical Association Trauma Branch,the Chinese Trauma Rescue Alliance,and the Editorial Committee of the Journal of Trauma Surgery jointly led the consensus writing team consisting of experts with extensive experience in the treatment of multiple trauma,and released the“Chinese Expert Consensus on Medical documentation and Diagnosis for Multiple Trauma(2023 edition)”(hereinafter referred to as“Consensus 2023”).This article introduces the basic information of Consensus 2023,provides a detailed interpretation of the definition and classification of multiple trauma in Consensus 2023,as well as the requirements for medical documentation and diagnosis of multiple trauma,for reference by trauma medical practitioners.
作者
李阳
张连阳
LI Yang;ZHANG Lianyang(Division of Trauma and War Injury,Daping Hospital,Army Medical University of PLA,Chongqing 400042,China)
出处
《西部医学》
2023年第9期1252-1255,1263,共5页
Medical Journal of West China
基金
陆军特色医学中心人才创新能力培养计划(2019CXLLA002)。
关键词
多发伤
专家共识
病历
诊断
共识解读
Multiple trauma
Expert consensus
Medical documentation
Diagnosis
Interpretation
