TMTraumaMaster Academy

课堂学习 · 2026-10 更新Classroom learning · October 2026 update

文书、告知与交接Documentation, communication and handover

把做过什么、为什么做、患者如何反应，以及谁继续负责，写得清楚。Record what happened, why, how the patient responded and who takes responsibility next.

来源与审核记录Sources and review record
Conceptual teaching illustration, not case evidence
教学示意，非病例影像。Teaching illustration, not case imaging.

预计学习Estimated learning time · 25 分钟min

学完这门课，你能……After this course, you can…

  1. 记录带时间的评估、措施、反应及未解问题。Record timed assessments, actions, response and unresolved concerns.
  2. 演练危重告知与知情同意的沟通要素。Practise critical-condition and informed-consent communication.
  3. 用责任人和复评时间闭环交接待办事项。Close handover tasks with an owner and reassessment time.
实习：识别与报告；规培：决策时机与监督下关键步骤；青年主治：团队指挥与资源调度。Intern: recognize/report; resident: decision timing and supervised key steps; early attending: team leadership and resources.
先做 5 题前测Start five-question pretest学完做 5 题后测Complete five-question posttest本课口袋卡Course pocket card
课前测 · 5 题Pretest · five questions

每题 1 分；用于形成性反馈。One point per item; formative feedback.

合成情境题Synthetic vignette 1. 32岁男性车祸伤员完成止血复苏，HR96次/min、BP118/72 mmHg、SpO₂97%。当前出血已控制，抢救期间忙于处置未能实时写病历，护士保留准确时间线。下一步最合适的是？A 32-year-old man has completed hemorrhage resuscitation after a collision; HR 96/min, BP 118/72 mmHg, SpO₂ 97%. Bleeding is controlled. Rescue prevented contemporaneous documentation; nursing timestamps are available. What is the most appropriate next step?
合成情境题Synthetic vignette 2. 32岁女性坠落伤员接受抢救，HR96次/min、BP118/72 mmHg、SpO₂97%。护士已复诵并执行口头医嘱，现抢救刚结束，药品、剂量与执行时间有记录。下一步最合适的是？A 32-year-old woman is resuscitated after a fall; HR 96/min, BP 118/72 mmHg, SpO₂ 97%. A nurse repeated and executed a verbal order; rescue has just ended and drug, dose and execution time were recorded. What is the most appropriate next step?
3. 急会诊已发出，国内规范的到场要求？What arrival deadline applies to an urgent consultation?
4. 参加抢救人员栏还应记录什么？What belongs beside rescue participant names?
5. 抢救时患方无法及时签署，谁处理紧急签署？Who addresses emergency signing when the lawful decision maker cannot sign promptly?
Conceptual teaching illustration
教学示意：用于理解任务与关系。Conceptual illustration of tasks and relationships.

01

抢救记录：时间与变化可追溯Resuscitation records: traceable time and change

  • 记录带时间的机制、初评、连续体征、决策依据、措施和反应。Record timed mechanism, assessment, serial findings, rationale, actions and response.
  • 阳性、阴性、未检查和不可靠结果分开写；注明信息来源。Distinguish positive, negative, unexamined and unreliable findings; identify the source.
  • 病危/病重通知、手术/输血等同意与正式病历使用本院认可文书。Use institutional records for critical-condition notification and surgical/transfusion consent.
Conceptual teaching illustration
教学示意：用于理解任务与关系。Conceptual illustration of tasks and relationships.

02

告知：让患者和家属理解下一步Communication: make the next step understandable

  • 说明当前危险、计划和不确定性，核对理解，约定下次更新。Explain risks, plans and uncertainty, check understanding and agree the next update.
  • 侵入操作沟通涵盖目的、获益风险、替代方案和患者选择。Discuss purpose, benefits/risks, alternatives and patient choice for invasive procedures.
  • 患者决策能力、代理与紧急授权按当地法规和本院制度处理。Capacity, representation and emergency authorization follow local law and institutional policy.
Conceptual teaching illustration
教学示意：用于理解任务与关系。Conceptual illustration of tasks and relationships.

03

交接：把未完成的任务交到人Handover: assign unfinished tasks to people

  • 按情况/背景/评估/建议组织，突出趋势和措施后反应。Organize situation, background, assessment and recommendation, highlighting trends and response.
  • 待回报结果、未检查区域、资源限制、复评时点和接班人逐项核对。Reconcile pending results, unexamined regions, resource limits, review times and the receiving clinician.
  • 用复述确认重点；记录交接时间、双方角色和未解问题。Confirm priorities by read-back; record timing, roles and unresolved concerns.

国内文书要求：时间、告知与签署Chinese record requirements: timing, consent and signatures

具体方案；以本院为准；每项数字同时核对人群、阶段和来源。Follow institutional protocols; check population, stage and source with every number.

抢救、告知与交接文书Resuscitation, consent and handover records

抢救结束后 ≤6 h 据实补记并注明；以本院规范为准。Truthful, marked supplementation ≤6 h after rescue ends Follow institutional policy.

仅限因抢救急危患者未能及时书写；不是所有病历可延迟。Only when urgent rescue prevented timely writing; not permission to delay all records.

时间到分钟；措施、反应、人员、告知与交接责任。Minute-level time, actions, responses, staff, communication and handover ownership.

签署困难记录原因并走合法授权/急救审批流程，不造签名或回填时间。Record signing difficulties and use lawful emergency authorization; never fabricate signatures/times.

病历书写基本规范（2010）Basic norms for medical record writing (2010) · 国家卫健委：临床用血技术规范（2025年版）NHC clinical blood use technical standard (2025)

国内外依据与适用差异Domestic/international scope differences

病历规范第22条(八)、25/27条；输血告知同步遵循2025用血规范。Record norms Article 22(8), 25/27; transfusion consent also follows 2025 blood-use standards.

来源核对日期：2026-10-14；临床审核：进行中Source check: 2026-10-14; clinical review: ongoing

国内写法练习：三个框架Chinese record exercises: three outlines

以下为无身份信息的教学框架，实际文书使用本院模板。These teaching outlines contain no identifiers; use institutional forms in practice.

抢救记录 / 补记Rescue record / supplementation

抢救起止时刻［ ］；病情及变化［ ］；措施与反应［ ］；参加人员［ ］；告知［ ］；去向与接收者［ ］。因抢救未能及时书写：补记时刻［ ］、原因［ ］、据实补记标注［ ］、医师签名［ ］。Rescue start/end [ ]; condition/change [ ]; actions/response [ ]; staff [ ]; communication [ ]; destination/receiver [ ]. If rescue prevented timely writing: supplementation time/reason/marking [ ]; physician signature [ ].

病危（重）通知Critical-condition notification

诊断与危重情况［ ］；告知时刻、对象及关系［ ］；病情风险与拟救治沟通［ ］；患方意见/签名［ ］；医师签名/日期［ ］。按第27条一式两份，患方与病历各保留一份。Diagnosis/critical condition [ ]; notification time, recipient/relationship [ ]; risks/care discussion [ ]; recipient response/signature [ ]; physician/date [ ]. Article 27: one copy for the recipient and one for the record.

输血知情同意Transfusion consent

诊断与输血指征［ ］；拟输成分［ ］；相关检查［ ］；输血风险及可能不良后果［ ］；患者或依法授权签署意见/签名［ ］；医师签名/日期［ ］。无法及时签署时记录原因，走合法急救授权流程。Diagnosis/indication [ ]; components [ ]; relevant tests [ ]; risks/adverse consequences [ ]; patient/lawfully authorized decision/signature [ ]; physician/date [ ]. If timely signing is impossible, record why and use lawful emergency authorization.

病历书写基本规范（2010）Basic norms for medical record writing (2010) · 国家卫健委：临床用血技术规范（2025年版）NHC clinical blood use technical standard (2025)

两种补记时限，不能混用Two supplementation deadlines that differ

抢救记录：6 hRescue record: six hours

因抢救未能及时书写，结束后6 h内据实补记并注明；记录时间到分钟。以本院规范为准。If rescue prevents timely writing, supplement truthfully and mark within six hours after rescue; timestamp to minutes. Follow institutional policy.

参加人员姓名及专业技术职称；主持抢救者审核签字。Record participant names and professional technical titles; the rescue leader reviews and signs.

口头医嘱：即刻Verbal order: immediately

仅限急危抢救必要情形；护士复诵，抢救结束后医师即刻据实补记（第28条）。For necessary emergency-rescue orders, the nurse repeats the order; the physician documents it immediately after rescue (Article 28).

不能将医嘱补记推迟到6 h期限；药名、剂量、途径及时间逐项核对。The six-hour record deadline does not extend the order deadline; verify drug, dose, route and time.

交接与急会诊Handover and urgent consultation

交班记录交班前完成；接班记录接班后24 h内完成；急会诊10 min内到场、结束后即刻完成记录。以本院规范为准。Outgoing record before handover; incoming record within 24 hours; urgent consultation arrival within ten minutes and record immediately after consultation. Follow institutional policy.

危重患者床旁交班、专册记录、双方签字；危急值记录、复读确认、立即通知医师并跟踪处理。Hand over critical patients at the bedside, with dedicated records and both signatures; record/read back/confirm critical values, notify the physician promptly and follow through.

病历书写基本规范（2010）Basic norms for medical record writing (2010) · 医疗质量安全核心制度要点（2018）Chinese core medical quality requirements (2018)

依据与适用范围Sources and scope

课后测 · 5 题Posttest · five questions

每题 1 分；用于形成性反馈。One point per item; formative feedback.

合成情境题Synthetic vignette 1. 47岁男性车祸伤员完成止血复苏，HR102次/min、BP112/70 mmHg、SpO₂96%。当前出血已控制，抢救期间忙于处置未能实时写病历，护士保留准确时间线。下一步最合适的是？A 47-year-old man has completed hemorrhage resuscitation after a collision; HR 102/min, BP 112/70 mmHg, SpO₂ 96%. Bleeding is controlled. Rescue prevented contemporaneous documentation; nursing timestamps are available. What is the most appropriate next step?
合成情境题Synthetic vignette 2. 47岁女性坠落伤员接受抢救，HR102次/min、BP112/70 mmHg、SpO₂96%。护士已复诵并执行口头医嘱，现抢救刚结束，药品、剂量与执行时间有记录。下一步最合适的是？A 47-year-old woman is resuscitated after a fall; HR 102/min, BP 112/70 mmHg, SpO₂ 96%. A nurse repeated and executed a verbal order; rescue has just ended and drug, dose and execution time were recorded. What is the most appropriate next step?
3. 急会诊通知发出后，应以哪个时限核查到场？After an emergency consult request, which arrival interval should be audited?
4. 抢救人员已有姓名，还需补充哪项身份信息？Rescue staff names are recorded; what professional detail is also required?
5. 抢救需紧急处置、患方不能及时签字，授权环节是什么？Emergency care requires timely action but the patient side cannot sign; what authorization is used?