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体格检查记录需按系统循序、客观真实且用规范化用语进行书写。在记录过程中,存在主要用语问题:⑴使用不规范医学用语;⑵错误描述;⑶记录顺序颠倒;⑷记录不全;⑸用词模棱两可;⑹用病名或症状学名称代替体征;⑺非客观真实记录;⑻勉强将体征分度;⑼笼统描述;⑽存在争议记录。只有关注和重视每一环节,齐抓共管,通过提高书写者对记录用语规范化的重要性认识、重视临床技能规范化培训、不断更新医学和人文知识、完善制度管理、出版社出版精品教材和医学期刊的编辑率先垂范等,体格检查记录用语规范化才能成为现实。
Physical examination records required by the system in an orderly, objective and true use of standardized words to write. In the process of recording, there are some main problems of language: (1) non-standard medical terms; (2) wrong description; (3) reversal of recording order; (4) incomplete record; (5) ambiguity of terms; ; ⑻ reluctantly subjective; ⑼ general description; ⑽ there is controversial records. Only pay attention to and pay attention to every aspect, make concerted efforts, by increasing the writer’s understanding of the importance of standardization of record language, attention to standardized training of clinical skills, continuous updating of medical and humanities knowledge, improve system management, publishers quality materials and medical journals Editors take the lead, etc., physical examination record language standardization can become a reality.