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危重症患者最新诊断的记录:需要一种系统的方法。

Documentation of Updated Diagnosis for Critically Ill Patients: Needs a Systematic Approach.

作者信息

Gurjar Mohan, Saran Sai, Saigal Saurabh

机构信息

Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) Department of Critical Care Medicine Lucknow, Uttar Pradesh India.

All India Institute of Medical Sciences (AIIMS) Department of Anaesthesiology and Critical Care Bhopal, Madhya Pradesh India.

出版信息

J Acute Med. 2025 Sep 1;15(3):108-111. doi: 10.6705/j.jacme.202509_15(3).0004.

Abstract

In critically ill patients, there is complexity and dynamicity of the disease as well as absence of specific template to cover all aspects of the diagnosis. Improving accuracy in the diagnosis documentation is not only an important aspect in the communication among clinicians, other healthcare providers and administrators for better patient's clinical management; their financial aspects and quality metrics; but might also influence the future research depending on these documentations. This brief report highlights a systematic approach for updated daily as well as final diagnosis in critically ill patients.

摘要

在危重症患者中,疾病具有复杂性和动态性,且缺乏涵盖诊断各个方面的特定模板。提高诊断记录的准确性不仅是临床医生、其他医疗服务提供者和管理人员之间进行沟通以更好地管理患者临床情况、财务状况和质量指标的重要方面;还可能会根据这些记录影响未来的研究。本简要报告重点介绍了一种用于危重症患者每日更新诊断以及最终诊断的系统方法。

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