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院前急救病历作为急、危、重伤病员进入医院之前所得到的医疗救治过程的真实记录,对其科学、系统的保管及利用不仅对病人有必要,也是急救中心的建设、管理及进行科研的重要资料。目前对院前急救病历的管理尚没有统一模式,我们尝试在狭义管理基础上,制作出一套计算机管理系统,疾病分类采用ICD-10编码,实践中体会到在检索、查询、统计等方面优于以往,方便、快捷,疾病分类的标准性提高。但该办法尚不成熟,现阐述如下,与同行共同探讨。
The pre-hospital emergency medical record is a true record of the medical rescue process obtained before emergency, critical, and severely ill patients enter the hospital. Its scientific and systematic storage and use is not only necessary for the patient but also the construction, management, and scientific research of the emergency center. Important information. At present, there is no unified model for the management of pre-hospital emergency medical records. We have attempted to create a computer management system based on narrow-minded management. ICD-10 coding is used for disease classification. Experience in search, query, and statistics is excellent in practice. In the past, it was convenient and fast, and the standard of disease classification improved. However, this method is not yet mature. Now it is elaborated as follows and discussed with the peers.