日间手术病历书写规范专家共识（2019年）

Expert consensus on the norms for writing medical records of day surgery (2019)

摘要:

随着国家医改层面促进日间手术的发展，日间手术占择期手术比例逐步提高。由于日间手术住院时间短、病种多、周转快，病历书写工作量较大，普通病历模板很难适用于日间手术发展的临床需要。目前国家层面尚缺乏统一的日间手术病历书写规范和标准。为促进和规范日间手术的发展，国家老年疾病临床医学研究中心（湘雅）组织专家，依据原卫生部《病历书写基本规范》（2010年版）和国家卫生计生委医疗管理服务指导中心《日间手术管理导则》（2016版征求意见稿），在《中南大学湘雅医院日间手术病历书写规范（2018）》的基础上制订《日间手术病历书写规范专家共识》。

Abstract:

With the development of day surgery promoted by the national health care reform, the proportion of day surgery in the elective surgeries is becoming increasingly higher. The ordinary medical record templates are difficult to meet the clinical requirements of the development of day surgery, due to its short length of hospital stay, multiple disease entities, rapid turnover of patients and heavy workload in writing the medical records. At present, there is no  uniform norm or standard for medical record writing of day surgery in our country. For promoting and standardizing the development of day surgery, the experts of the National Clinical Research Center for Geriatric Disorders (Xiangya) developed the Expert Consensus on the Norms for Writing Medical Records of Day Surgery, based on the Xiangya Norms for Writing Medical Records of Day Surgery (2018) and in accordance with the Basic Norms for Writing Medical Records (2010) proposed by the previous Ministry of Health of China and the Guidelines for Management of Day Surgery (2016 exposure draft) recommended by the National Health and Family Planning Commission.