[专家共识:倡导使用手术图文记录(2025年版)]。

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引用次数: 0

摘要

手术记录是外科临床中心医疗文件的核心组成部分。手术记录标准化有助于规范手术流程,提高手术质量,保障患者安全。为了保证手术记录更加客观、直观、全面地反映手术的实际过程,许多高水平大学医院的外科中心一直坚持“图文结合”的格式记录手术记录的优良传统。图形化的手术记录不仅有利于术后回顾和结构化的数据收集,而且有利于实施高质量的临床研究和手术培训。早在2015年,中华医学会外科学分会外科手术组就制定了《关于倡导使用外科图文病历的专家共识》。近年来,信息技术的飞速发展,为手术图形化病历的进一步推广提供了技术支持。经过广泛的多轮专业讨论和调研,在充分考虑国家相关政策要求、信息标准的基础上,拟修订2025年版《专家共识》,旨在加强手术病历图形化标准化,提高手术、培训体系质量和临床研究质量,为健康中国的发展贡献力量。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
[Expert consensus on advocating the use of graphic surgical records(2025 edition)].

Surgical records are the core components of medical documents in clinical centers of surgery. Standardization of surgical records contributes to standardizing surgical procedures, improving the quality of surgery, and ensuring patient safety. To ensure that surgical records more objectively, visually, and comprehensively reflect the actual surgical process, numerous high-level university hospitals' surgical centers have long adhered to the good tradition of documenting surgical records in a "combination of text and images" format. Graphic surgical records not only benefit postoperative review and structured data collection but also facilitate the implementation of high-quality clinical research and surgical training. As early as 2015, Group of Operative Surgery, Chinese Society of Surgery, Chinese Medical Association already formulated the "Expert Consensus on Advocating the use of graphic surgical records".In recent years, rapid development of information technology has provided technical support for the further promotion of graphical surgical records. After extensive and multiple rounds of professional discussions and investigations, and based on a thorough consideration of relevant national policy requirements, information standards, the 2025 edition of the "Expert Consensus" is intended to be revised, aiming to enhance the standardization of graphical surgical records, improve the quality of surgery and training system, as well as clinical researches, thereby contributing to the development of Healthy China.

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来源期刊
CiteScore
0.80
自引率
0.00%
发文量
20861
期刊介绍: Chinese Journal of Surgery|Chin J Surg (monthly) is a high-level medical science and technology journal approved by the General Administration of Press and Publication of the People's Republic of China, under the supervision of the China Association for Science and Technology, and organised by the Chinese Medical Association for domestic and international public circulation. It was founded in January 1951, and is published on the basis of the Journal of Chinese Surgery. The Journal is aimed at senior and intermediate surgeons and related researchers, mainly reporting the leading scientific research results and clinical experience in the field of surgery, as well as the basic theoretical research that has a guiding effect on the clinical work of surgery. Chinese Journal of Surgery|Chin J Surg is committed to reflecting the major research progress in the field of surgery in China and promoting academic exchanges at home and abroad. The main columns include thesis, meta-analysis, review, expert forum, synthesis, case report, diagnosis and treatment experience, technical exchange, clinical case discussion, academic controversy, and special lectures, etc. The journal has been accepted by the National Academy of Medicine of the United States. The journal has been included in many famous databases at home and abroad, such as the Biomedical Analysis and Online Retrieval System (MEDLINE) of the U.S. National Library of Medicine.
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