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创面修复科病史采集全国专家共识(2021年版)

2021-12-01 中华医学会烧伤外科学分会 中华损伤与修复杂志(电子版)

创面修复病史采集

病史采集主要是由临床医师通过系统问诊获取临床资料,结合体格检查、实验室及器械检查等从而完成患者入院记录及门诊病历书写。

中文标题：

创面修复科病史采集全国专家共识(2021年版)

发布机构：

中华医学会烧伤外科学分会

发布日期：

2021-12-01

简要介绍：

病史采集主要是由临床医师通过系统问诊获取临床资料,结合体格检查、实验室及器械检查等从而完成患者入院记录及门诊病历书写。目前临床普遍存在病历内容记录不完整、不规范,病历收集不及时、图片资料缺失及质量不高、无法与国际接轨等情况。为提升创面修复科的病史采集规范化水平,专家组根据国内目前病历收集情况,结合国内外报道,从病史信息采集表格化、创面拍摄方面进行阐述,探讨如何在病史采集过程中和患者参与模式下提高临床医师的工作效率和病历质量,并减少医疗隐患。 

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1188500, encodeId=8a7b118850001, content=如何才能知道不留疤超好看, beContent=null, objectType=guider, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=18e75602622, createdName=ms8000000900080391, createdTime=Thu Jan 27 07:07:25 CST 2022, time=2022-01-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1180805, encodeId=46ca1180805f4, content=赞, beContent=null, objectType=guider, channel=null, level=null, likeNumber=168, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d5232168793, createdName=九歌L, createdTime=Wed Jan 05 10:22:53 CST 2022, time=2022-01-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1179922, encodeId=1e9d11e9922fd, content=学习了, beContent=null, objectType=guider, channel=null, level=null, likeNumber=163, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f7f61384374, createdName=411395, createdTime=Mon Jan 03 07:31:25 CST 2022, time=2022-01-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1179915, encodeId=73ab11e9915b8, content=好好学习，天天向上, beContent=null, objectType=guider, channel=null, level=null, likeNumber=155, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3e495565045, createdName=王江军, createdTime=Mon Jan 03 06:18:25 CST 2022, time=2022-01-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1179907, encodeId=e96811e99073d, content=学习学习学习, beContent=null, objectType=guider, channel=null, level=null, likeNumber=175, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=47445626421, createdName=ms6000001387765207, createdTime=Mon Jan 03 01:40:48 CST 2022, time=2022-01-03, status=1, ipAttribution=)]
    2022-01-27 ms8000000900080391

    如何才能知道不留疤超好看

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1188500, encodeId=8a7b118850001, content=如何才能知道不留疤超好看, beContent=null, objectType=guider, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=18e75602622, createdName=ms8000000900080391, createdTime=Thu Jan 27 07:07:25 CST 2022, time=2022-01-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1180805, encodeId=46ca1180805f4, content=赞, beContent=null, objectType=guider, channel=null, level=null, likeNumber=168, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d5232168793, createdName=九歌L, createdTime=Wed Jan 05 10:22:53 CST 2022, time=2022-01-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1179922, encodeId=1e9d11e9922fd, content=学习了, beContent=null, objectType=guider, channel=null, level=null, likeNumber=163, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f7f61384374, createdName=411395, createdTime=Mon Jan 03 07:31:25 CST 2022, time=2022-01-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1179915, encodeId=73ab11e9915b8, content=好好学习，天天向上, beContent=null, objectType=guider, channel=null, level=null, likeNumber=155, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3e495565045, createdName=王江军, createdTime=Mon Jan 03 06:18:25 CST 2022, time=2022-01-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1179907, encodeId=e96811e99073d, content=学习学习学习, beContent=null, objectType=guider, channel=null, level=null, likeNumber=175, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=47445626421, createdName=ms6000001387765207, createdTime=Mon Jan 03 01:40:48 CST 2022, time=2022-01-03, status=1, ipAttribution=)]
    2022-01-05 九歌L

    赞

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1188500, encodeId=8a7b118850001, content=如何才能知道不留疤超好看, beContent=null, objectType=guider, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=18e75602622, createdName=ms8000000900080391, createdTime=Thu Jan 27 07:07:25 CST 2022, time=2022-01-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1180805, encodeId=46ca1180805f4, content=赞, beContent=null, objectType=guider, channel=null, level=null, likeNumber=168, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d5232168793, createdName=九歌L, createdTime=Wed Jan 05 10:22:53 CST 2022, time=2022-01-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1179922, encodeId=1e9d11e9922fd, content=学习了, beContent=null, objectType=guider, channel=null, level=null, likeNumber=163, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f7f61384374, createdName=411395, createdTime=Mon Jan 03 07:31:25 CST 2022, time=2022-01-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1179915, encodeId=73ab11e9915b8, content=好好学习，天天向上, beContent=null, objectType=guider, channel=null, level=null, likeNumber=155, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3e495565045, createdName=王江军, createdTime=Mon Jan 03 06:18:25 CST 2022, time=2022-01-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1179907, encodeId=e96811e99073d, content=学习学习学习, beContent=null, objectType=guider, channel=null, level=null, likeNumber=175, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=47445626421, createdName=ms6000001387765207, createdTime=Mon Jan 03 01:40:48 CST 2022, time=2022-01-03, status=1, ipAttribution=)]
    2022-01-03 411395

    学习了

    0

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    2022-01-03 王江军

    好好学习，天天向上

    0

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    2022-01-03 ms6000001387765207

    学习学习学习

    0

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