超声诊断报告要标准化规范化

来源 :中国超声诊断杂志 | 被引量 : 0次 | 上传用户:flysky1979
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现在和将来,不管医学模式怎样转变,但影像医学日新月异的发展,特别是超声诊断技术在临床中都始终占有举足轻重的地位。那么,超声诊断报告是反映超声诊断医生的思维逻辑和印象诊断,是反映病人疾病现象和本质的客观记录;是临床医生诊断和处理疾病的重要依据;是动态观察疾病变化的真实对照;是基础医学、临床、教学、科研、学术交流的典型教材,然而,笔者近几年收集数十种全国各医科大学附属医院,大中城市医院、地县医院、乃至乡镇医院、部队工矿医院的各类超声诊断报告来看,发现诊断报告内容不一,格式不一,有的繁琐复杂,有的过于简单。总的结果是,各地各院各 Now and in the future, no matter how the medical model changes, the ever-changing development of imaging medicine, especially the ultrasound diagnosis technology, has always played a decisive role in the clinic. So, the ultrasound diagnosis report reflects the thinking logic and impression diagnosis of the ultrasound diagnosis doctor, and is an objective record reflecting the patient’s disease phenomenon and essence; it is an important basis for clinicians to diagnose and treat diseases; it is a real contrast of dynamic observation of disease changes; is the basis Typical textbooks for medical, clinical, teaching, scientific research, and academic exchanges. However, in recent years, the author has collected dozens of types of affiliated hospitals of various medical universities across the country, large and medium-sized urban hospitals, prefectural hospitals, even township hospitals, and military and mining hospitals. According to the ultrasound diagnosis report, the contents of the diagnostic report were found to be different, the formats were different, some were complicated and some were too simple. The overall result is that each local court
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