摘要
多发伤病历书写争议颇多,国际疾病分类第10次修订本(ICD-10)不能满足其诊断要求。本文系统阐述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3部分,损伤诊断排列应遵循由上而下、从内向外和先重后轻原则。
There are many disputes on the writing of clinical record for multiple injury,and the ICD-10 can＇t be qualified for the requirement of multiple injury diagnosis.In this paper,the main points of clinical record writing for multiple injury are elucidated systematically.It is believed that the diagnosis of multiple injury should include diagnosis of injury,diagnosis of complications and diagnosis of coexistent disease,and the disposition of diagnosis in the clinical record should follow the sequence of head-toe,inside-outside and severe-mild.
出处
《创伤外科杂志》
2010年第1期96-96,F0003,共2页
Journal of Traumatic Surgery
基金
全军医学卫生科研基金专项课题(08Z024)
关键词
多发伤
病历
诊断
意见
multiple injury
clinical record
diagnosis
consensus
