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胸外科临床疾病主要分类为良性、恶性,有其特定的临床表现及体征,且多数需要手术干预,不论是传统的手术方式或微创手术方式,都有特征性的基本规律。在依法执业中的医疗行为均会通过病案被记录下来,必然会产生大量的诊疗信息和诊疗数据。而胸外科医师最为关注的病案数据主要包括病史、病理、手术方式、治疗方案、高证据力的辅助检查、心肺功能、伴随疾病、治疗效果、综合医疗风险评估。病案书写、病案信息的质量不仅会影响临床实践、临床教学、临床科研数据的精准性、完整性,还会影响到产生课题及文章中的数据应用的科学性、逻辑性、真实性,最终影响到病例积累行成的数据库质量。做为胸外科各级医师,务必加以重视,写好每份临床病案。
Thoracic surgical diseases are mainly classified as benign and malignant, with their specific clinical manifestations and signs, and most require surgical intervention, either traditional or minimally invasive surgical approach has a characteristic basic law. Medical practice in accordance with the law will be recorded through the medical record, will inevitably produce a large number of diagnosis and treatment information and treatment data. The most important case data of thoracic surgeons include medical history, pathology, operation mode, treatment plan, high-proof auxiliary examination, cardiopulmonary function, concomitant diseases, therapeutic effect, and comprehensive medical risk assessment. The record of the medical record and the quality of medical record information will not only affect the accuracy and completeness of the clinical practice, clinical teaching and clinical research data, but also affect the scientific, logical, authenticity and ultimate impact of the application of the data in the generated questions and articles To the accumulation of cases into the database quality. As a physician at all levels of thoracic surgery, be sure to pay attention to write down every clinical case.