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中华医学会创伤学分会创伤急救与多发伤学组
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【ÖÐͼ·ÖÀàºÅ】Ｒ 641【ÎÄÏ×±êʶÂë】A
Consensus on medical documentation and diagnosis of multiple injury
Trauma Care and Multiple Injury Group of Traumatology Society of Chinese Medical Association
【Abstract】There are many disputes on the writing of clinical record for multiple injury£¬and the ICD-10
couldn't be qualified for the diagnosing requirement of multiple injury． In this paper£¬the main points of clinical re-
cord writing for multiple injury were initially elucidated systematically． It was believed that the diagnosis of multiple
injury should include diagnosis of injury£¬diagnosis of injury complications and diagnosis of concomitance diseases£¬
and the disposition of diagnosis in the clinical record should follow the sequence of head-toe£¬inside-outside and se-
vere-slight．
【Key words】multiple injury;clinical record;diagnosis;
professor
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(2012BAI11B01)
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多发伤病历与诊断：专家共识意见（2013版）.pdf