科学技术的发展,电子计算机在医学领域中的广泛应用,要求临床第一诊断准确而全面。本文探讨临床第一诊断的确定,并阐述在医院管理和医疗质量管理中的意义。一、传统的诊断书写模式: 传统的诊断书写模式大致有四种:第一种,按疾病的病因、病理解剖、病理生理和功能障碍的顺序书写。如风湿性心脏病(病因诊断),二尖瓣狭窄和关闭不全(病理诊断),心房颤动(病理生理诊断),充血性心力衰竭,心功能Ⅲ级(功能诊断)。第二种,按疾病发 With the development of science and technology, the widespread use of electronic computers in the medical field requires accurate and comprehensive clinical diagnosis. This article discusses the determination of the first clinical diagnosis and describes the significance in hospital management and medical quality management. First, the traditional diagnostic writing mode: There are roughly four traditional diagnostic writing modes: The first is written in the order of the disease’s etiology, pathological anatomy, pathophysiology, and dysfunction. Such as rheumatic heart disease (etiology diagnosis), mitral valve stenosis and insufficiency (pathological diagnosis), atrial fibrillation (pathophysiological diagnosis), congestive heart failure, cardiac function class III (functional diagnosis). The second, according to the disease