癌症病史的要紧性超乎你的想象，该怎么样收集整理病历资料？
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">前 言</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">写这篇<span style="color: black;">文案</span>的想法由来已久，关于病史材料的<span style="color: black;">关联</span>内容<span style="color: black;">亦</span>和临床肿瘤<span style="color: black;">大夫</span>以及医学顾问进行了<span style="color: black;">长时间</span>的沟通，而近期<span style="color: black;">咱们</span>服务的一位<span style="color: black;">病人</span>的经历加速了<span style="color: black;">咱们</span>对<span style="color: black;">关联</span>内容的整理。该<span style="color: black;">病人</span><span style="color: black;">拜托</span><span style="color: black;">咱们</span>咨询美国<span style="color: black;">大夫</span><span style="color: black;">得到</span>第二意见，<span style="color: black;">同期</span><span style="color: black;">拜托</span>授权<span style="color: black;">咱们</span><span style="color: black;">帮忙</span>收集在国内医院的病历资料。此前该<span style="color: black;">病人</span>在国内排名前五的综合医院<span style="color: black;">看病</span>，<span style="color: black;">然则</span>当<span style="color: black;">咱们</span>带着患者的身份证复印件前往该医院档案室调取该<span style="color: black;">病人</span>病历资料的时候，<span style="color: black;">没</span>论<span style="color: black;">怎样</span><span style="color: black;">亦</span>找不到病理报告这一至关<span style="color: black;">要紧</span>的病历资料。实在是让人很绝望啊。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">这种级别的医院，病史资料的管理都如此不规范，其他医院的<span style="color: black;">状况</span>就可想而知了。<span style="color: black;">然则</span>过往的病历资料对癌症<span style="color: black;">病人</span>来讲是至关<span style="color: black;">要紧</span>的，远远超出<span style="color: black;">病人</span>和家属的想象，<span style="color: black;">咱们</span>特意撰写本文，描述了癌症病历资料都<span style="color: black;">包含</span><span style="color: black;">那些</span>，<span style="color: black;">要紧</span>性<span style="color: black;">表现</span>在哪里，以及<span style="color: black;">病人</span>和家属该<span style="color: black;">怎样</span>收集整理等信息，<span style="color: black;">期盼</span>对广大癌症<span style="color: black;">病人</span>及家属在病历资料的收集和整理上有所<span style="color: black;">帮忙</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">癌症病历资料对谁比较<span style="color: black;">要紧</span>？</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">病历资料<span style="color: black;">不但</span>是对治疗结束的癌症<span style="color: black;">病人</span><span style="color: black;">要紧</span>，对和癌症<span style="color: black;">关联</span>的所有<span style="color: black;">病人</span>和家属都很<span style="color: black;">要紧</span>。</p><span style="color: black;">可疑</span>癌症的<span style="color: black;">病人</span>，例如因肺部结节正在随访的<span style="color: black;">病人</span>新发（刚诊断出来）的癌症<span style="color: black;">病人</span>治疗过程中的癌症<span style="color: black;">病人</span><span style="color: black;">恢复</span><span style="color: black;">周期</span>的癌症<span style="color: black;">病人</span>癌症<span style="color: black;">病人</span>家属<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">癌症病历资料以及病史都指的是什么？</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">在正式<span style="color: black;">起始</span>描述之前，有两个<span style="color: black;">要紧</span>的基本概念要和<span style="color: black;">大众</span>普及，即病历资料和病史都是什么。 </p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">病历资料是什么？</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">病历资料是<span style="color: black;">病人</span>患病就诊、治疗和<span style="color: black;">恢复</span>随访过程所有客观记录的原始资料的总<span style="color: black;">叫作</span>（<span style="color: black;">包含</span>复印件）。这<span style="color: black;">包含</span><span style="color: black;">大夫</span>书写的或<span style="color: black;">经过</span>电脑打印的门诊病历，住院记录，手术记录，放疗记录，化疗记录，病理报告，基因检测报告，内镜报告，化验单及影像（CT、MRI和PETCT）等纸质报告，<span style="color: black;">亦</span><span style="color: black;">包含</span><span style="color: black;">各样</span>影像CT/MRI和PETCT<span style="color: black;">检测</span>资料（胶片或DICOM电子版）。当然<span style="color: black;">亦</span><span style="color: black;">包含</span>住院门诊缴费的<span style="color: black;">各样</span>单据。</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic4.zhimg.com/80/v2-70ad3747d09ddcd1753217a8f06da47f_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">病历资料是病人治疗过程的客观记录，肿瘤的<span style="color: black;">出现</span>发展<span style="color: black;">状况</span>的客观描述。对<span style="color: black;">日前</span><span style="color: black;">状况</span>的判断，进一步的治疗和<span style="color: black;">恢复</span>等<span style="color: black;">必须</span>采取的<span style="color: black;">恰当</span><span style="color: black;">办法</span>，<span style="color: black;">供给</span>了<span style="color: black;">要紧</span>的<span style="color: black;">指点</span>依据。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">这些资料的缺失或不准确，极有可能会使下一步的治疗失去方向，<span style="color: black;">引起</span>误诊误治，<span style="color: black;">导致</span>治疗的不规范从而治疗效果<span style="color: black;">不良</span>或产生严重的毒副<span style="color: black;">功效</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">那样</span>病史小结又是什么？</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">将<span style="color: black;">以上</span><span style="color: black;">病人</span>原始的病历资料，<span style="color: black;">根据</span><span style="color: black;">病人</span><span style="color: black;">检测</span>和治疗的经过，用医学的语言和格式整理记录后的文件<span style="color: black;">叫作</span>为病史。病史是对<span style="color: black;">病人</span>诊疗经过（<span style="color: black;">包含</span>治疗方式和效果），原始的<span style="color: black;">检测</span>报告和影像资料等的医学小结，有时候<span style="color: black;">咱们</span><span style="color: black;">亦</span><span style="color: black;">叫作</span>为病史小结。英语对应的有多种说法：Medical summary, Case History等讲的都是同<span style="color: black;">同样</span>事情。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">癌症<span style="color: black;">病人</span>就诊的时候，<span style="color: black;">能够</span>不<span style="color: black;">供给</span>病史小结，<span style="color: black;">然则</span>完整的原始病历资料<span style="color: black;">必要</span><span style="color: black;">供给</span>给<span style="color: black;">大夫</span>。病史小结的好处是<span style="color: black;">大夫</span>能在很短的时间内<span style="color: black;">认识</span><span style="color: black;">病人</span>既往的诊断和治疗经过，不<span style="color: black;">必须</span>把时间花在翻找<span style="color: black;">各样</span>资料上，而是把时间花在解释病情，制订下一步治疗随访<span style="color: black;">方法</span>上，能<span style="color: black;">极重</span><span style="color: black;">提高</span>医患沟通的效率，取得最佳的就诊效果。病史小结<span style="color: black;">针对</span>发病时间长达数年的<span style="color: black;">病人</span>，尤为<span style="color: black;">要紧</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">下图为<span style="color: black;">咱们</span>整理的一位病程较长的肺癌患者的病史小结，长达5年多的病史经历，<span style="color: black;">大夫</span>只<span style="color: black;">必须</span>阅读一页纸就能基本<span style="color: black;">认识</span>，避免了<span style="color: black;">病人</span>和家属描述的不准确和不完整等问题（<span style="color: black;">意见</span>点击看大图）：</p>
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