Existing problems and suggestions for medical record writing in trauma surgery / 中华创伤杂志

ABSTRACT

Medical record writing in trauma surgery differs from that of conventional surgery. The medical records in trauma surgery encompass the entire process of trauma management, serving as an indication of expertise in trauma management and treatment effectiveness. At present, most medical records in trauma surgery are written in the conventional writing mode of various surgical specialties, which fails to indicate the overall injury situation of trauma patients and the process of diagnosis and treatment, resulting in unevenly qualified medical records in trauma surgery, which hinders trauma treatment and academic exchange. Given that trauma assessment owns unique nuances, conventional physical examination methods are not entirely applicable to trauma patients. Moreover, with the advancement of diagnostic and therapeutic technologies, certain physical examination techniques and medical procedures that may induce pain, impede timely rescue, or even cause injury can be circumvented in clinical assessment. As theories, techniques, and disciplines in trauma care continue to develop, there arises a need for further standardization and uniformity in medical record writing in trauma surgery. By analyzing the special characteristics of medical record writing in trauma surgery, the authors sorted out and summarized the problems in medical record writing and put forward suggestions on improvement of medical records in trauma surgery to provide reference for standardization of medical record writing in trauma surgery and improvement of the comprehensive strength of trauma treatment.