多发伤病历与诊断：专家共识2023版

创伤外科杂志2023年第25卷第8期J Trauma Surg,2023,Vol.25,No.8·561··共识与指南·多发伤病历与诊断：专家共识(2023版)李阳，李辉2，陈驾君3，许永安4，朱风雪5，李占飞3，都定元2，王天兵5，张茂4，白祥军3，张连阳，国家创伤医学中心，创伤与化学中毒全国重点实验室，中华医学会创伤学分会创伤急救与多发伤学组，中国创伤救治联盟，《创伤外科杂志》编辑委员会1.陆军军医大学大坪医院，创伤与化学中毒全国重点实验室，重庆400042；2.重庆市急救医疗中心/重庆大学附属中心医院，重庆400014；3.华中科技大学同济医学院附属同济医院/国家重大公共卫生事件医学中心，武汉430030；4.浙江大学医学院附属第二医院，杭州310009：5.北京大学人民医院（国家创伤医学中心），北京100044【摘要】随着创伤救治体系的完善和技术的普及，我国的多发伤救治得以快速发展。多发伤是创伤中心核心病种，而多发伤的病历书写和诊断仍存在争议。为规范多发伤的病历和诊断，促进创伤救治质量控制体系的建立，现制定《多发伤病历与诊断：专家共识(2023版)》。本共识对多发伤的定义进行了修改，强调了病历首页主要诊断、其他诊断以及手术和操作的填写内容。此外，共识还与相关的规范和分类保持一致，以便于统一认识和学术交流。【关键词】多发伤：专家共识：病历；诊断【中图分类号】R641【文献标识码】A【D0I】10.3969/j.issn.1009-4237.2023.08.001Chinese expert consensus on medical documentation and diagnosis for multiple trauma (2023edition)Li Yang',Li Hui,Chen Jiqjun,Xu Yongan',Zhu Fengxue,Li Zhanfei,Du Dingyuan2,Wang Tianbing ,Zhang Mao',Bai Xiangjun,Zhang Lianyang',National Trauma Medical Center;State Key Laboratory of Trauma and Chemical Poisoning;Trauma First Aid andMultiple Trauma Group,Chinese Society of Medicine;China Trauma Alliance;Editorial Board of Journal of Traumatic Surgery1.State Key Laboratory of Trauma and Chemical Poisoning,Daping Hospital,Army Medical University,Chongqing 400042,China;2.Chongqing Emergency Medical Center/Central Hospital Chongqing University,Chongqing 400014,China;3.National Center forMajor Public Health Events,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan430030,China;4.The Second Affiliated Hospital of Zhejiang University School of Medicine,Hangzhou 310009,China;5.Peking U.niversity People's Hospital,Beijing 100044,China[Abstract]With the improvement and popularization of trauma care system and related rescue techniques,the management of multiple trauma has rapidly developed in China.Multiple trauma is the core disease in all levelsof trauma centers,yet there are still controversies over its medical documentation and diagnosis.In order to standard-ize this issue and promote the establishment of a quality control system for trauma care,the updated version of Chi-nese expert consensus on medical documentation and diagnosis for multiple trauma (2023 edition)is released.Thisconsensus has modified the definition of multiple trauma and emphasizes the medical documentation of its primarydiagnosis,secondary diagnoses,and surgical procedures in medical records.Additionally,the present consensuskeeps consistent with relevant standards and classifications,to facilitate the unified understanding and academic com-munication.Key words]Multiple trauma;Expert consensus;Medical documentation;Diagnosis自20世纪80年代以来，随着创伤救治体系的完善、损害控制技术的普及，我国多发伤的规范化救【通信作者】张连阳，E-mail:hpzhangly(@163.com白祥军，E-mail:baixiangjun@hotmail.com张茂，E-mail:mmhz@hotmail.com王天兵，E-mail:wangtianbing(@pkuph.edu.cm都定元，E-mail:dudingyuan@qg.com李阳和李辉对本文有同等贡献