【摘要】：隨著臨床肺功能檢查的廣泛應(yīng)用,檢查項(xiàng)目逐步增多,對(duì)肺功能報(bào)告的要求越來(lái)越高。特別是對(duì)肺部疾病的功能分級(jí)診斷和圍手術(shù)期風(fēng)險(xiǎn)評(píng)估意義重大,涉及臨床各科室,有些醫(yī)院胸腹部手術(shù)和其他重大手術(shù)肺功能被納入臨床路徑,由于大部分非呼吸專業(yè)的臨床醫(yī)生對(duì)肺功能報(bào)告的解讀依賴于肺功能診斷醫(yī)生的書寫報(bào)告,肺功能結(jié)果是通過(guò)報(bào)告的形式表現(xiàn)出來(lái),反映出所有的檢查內(nèi)容、質(zhì)量控制、診療標(biāo)準(zhǔn)、專業(yè)知識(shí)背景及進(jìn)一步的診療建議等信息,一份合格的肺功能報(bào)告可以從多層面詮釋呼吸疾病的病理生理改變,幫助臨床對(duì)呼吸疾病的診斷與鑒別診斷、療效評(píng)價(jià)、風(fēng)險(xiǎn)評(píng)估、估計(jì)預(yù)后提供準(zhǔn)確信息。但在我們的實(shí)際工作中關(guān)于肺功能結(jié)果判斷標(biāo)準(zhǔn)存在認(rèn)識(shí)上的差異,缺乏規(guī)范化的標(biāo)準(zhǔn),加之肺功能檢查儀型號(hào)各異,檢查項(xiàng)目不同,因此在書寫肺功能診斷報(bào)告時(shí)難免存在多個(gè)版本,出現(xiàn)地域之間和各醫(yī)院之間診斷標(biāo)準(zhǔn)不統(tǒng)一、隨意性、個(gè)性化等問(wèn)題,在不同的醫(yī)院或不同的肺功能檢查室相同的檢查結(jié)果,不同的診斷結(jié)論的事件頻出,不利于醫(yī)療風(fēng)險(xiǎn)的控制,與當(dāng)今現(xiàn)代醫(yī)學(xué)發(fā)展和規(guī)范化管理的模式不相適應(yīng)。針對(duì)肺功能書寫過(guò)程中存在的問(wèn)題,如:書寫格式、內(nèi)容、措辭、隨意性等,依據(jù)肺功能診斷分級(jí)標(biāo)準(zhǔn)及COPD肺功能診斷標(biāo)準(zhǔn),研發(fā)創(chuàng)建了電子版《M.H肺功能診斷應(yīng)用軟件》系統(tǒng),獲國(guó)家計(jì)算機(jī)軟件著作權(quán)。經(jīng)過(guò)一年的試用其性能穩(wěn)定、資料電子存檔便于查詢、功能可擴(kuò)展、可與醫(yī)院網(wǎng)絡(luò)系統(tǒng)對(duì)接。規(guī)范了本實(shí)驗(yàn)室肺功能診斷報(bào)告,提高了肺功能診斷水平,同時(shí)也利于質(zhì)量控制、進(jìn)修帶教、培訓(xùn)考核等工作。
[Abstract]:With the wide application of clinical pulmonary function examination, the item of examination is increasing gradually, and the requirement of lung function report is higher and higher. In particular, it is of great significance for the functional grading diagnosis and perioperative risk assessment of lung diseases, involving all clinical departments, and some hospitals have included chest and abdomen operations and other major operations in the clinical pathway. Since most non-respiratory clinicians interpret lung function reports on the basis of written reports by the pulmonary function diagnostics, the results of lung function are expressed in the form of reports, reflecting all the examination contents and quality control. A qualified lung function report can interpret the pathophysiological changes of respiratory diseases in many ways, help the clinical diagnosis and differential diagnosis of respiratory diseases, and evaluate the curative effect. Risk assessment, estimation of prognosis provides accurate information. However, in our practical work, there are differences in understanding of the criteria for judging the results of lung function, lack of standardized standards, and different types of pulmonary function examination instruments and different examination items. Therefore, in writing the pulmonary function diagnosis report, there are inevitably many versions, and there are problems such as inconsistent, arbitrary and individualized diagnostic criteria between regions and hospitals, and the same results in different hospitals or different lung function examination rooms. The frequent occurrence of different diagnostic conclusions is not conducive to the control of medical risk and is not suitable for the development of modern medicine and standardized management. In view of the problems existing in the process of pulmonary function writing, such as writing format, content, wording, randomness, etc., according to the criteria of pulmonary function diagnosis and grading and COPD diagnostic criteria of lung function, Developed and created the electronic version of "M.H lung function diagnosis application software" system, the national computer software copyright. After one year's trial, its performance is stable, data archiving is easy to query, its function can be expanded, and it can be docked with hospital network system. The diagnostic report of pulmonary function in our laboratory is standardized, and the diagnostic level of pulmonary function is improved. It is also beneficial to quality control, further education, training examination and so on.
【作者單位】： 新疆維吾爾自治區(qū)人民醫(yī)院呼吸功能檢查科;
【分類號(hào)】：TP319;R563
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本文編號(hào)：2421325