肿瘤预防与治疗2026，Vol.39Issue(7)：515-523,9.DOI:10.3969/j.issn.1674-0904.2026.07.001
四川省肺癌诊疗病历书写标准化实践(2026版)
Standardized Practice of Medical Record Writing for Lung Cancer Diag-nosis and Treatment in Sichuan Province(2026 Edition)
摘要
Abstract
General medical record templates are widely adopted for inpatient medical records of lung cancer in China,which are plagued by the lack of disease-specific core elements,insufficient reflection of clinical reasoning,and poor align-ment with quality control criteria.These issues impede the standardized and homogeneous development of lung cancer diagno-sis and treatment,as well as medical insurance review,big data analysis and the translation of research findings.To stand-ardize lung cancer medical record writing and strengthen quality control,the Lung Cancer Subspecialty Group of Sichuan Pro-vincial Medical Quality Control Center for Oncological Diseases developed the Standardized Practice for Medical Record Writ-ing in Lung Cancer Diagnosis and Treatment in Sichuan Province(2026 Edition),based on national lung cancer guidelines,medical quality control indicators,and medical record writing specifications.This practice specifies structured writing key points and core elements from three dimensions:admission records,pre-systemic treatment plans,and post-antitumor treat-ment summaries,with attached structural frameworks and examples.This practice aims to shift medical record writing from"formal compliance"to"substantive standardization",to provide actionable clinical references for clinicians,and to contrib-ute to the improvement of lung cancer diagnosis and treatment quality and patient outcomes.关键词
肺癌/病历书写/质量控制/诊疗规范Key words
Lung cancer/Medical record writing/Quality control/Diagnosis and treatment specification分类
医药卫生引用本文复制引用
四川省肿瘤性疾病医疗质量控制中心肺癌亚专业组,姚文秀,唐建宁..四川省肺癌诊疗病历书写标准化实践(2026版)[J].肿瘤预防与治疗,2026,39(7):515-523,9.基金项目
This study was supported by grants from Health Comission of Sichuan Province(No.YB2024031).2024年四川省临床重点专科[肿瘤科(肿瘤内科方向)](编号:YB2024031) （No.YB2024031）
