心电图报告规范化书写专家共识(2026)

doi:10.6040/j.issn.1671-7554.0.2025.1583

摘要/Abstract

摘要： 心电图是临床应用最广泛的无创性心脏检查技术之一。然而,国内各级医疗机构在心电图报告的格式、诊断术语及书写层次等方面存在差异,这种“同图不同报”的现象给临床诊疗、医学教学及科学研究带来了诸多困扰。为推进我国心电图诊断报告的规范化、标准化与同质化进程,山东省医学会心电学分会组织相关领域专家,在充分参考国内外文献与指南的基础上,结合我国临床实践,制定本专家共识。本共识系统阐述心电图数据采集的注意事项,明确报告的基本结构与要素,规范正常心电图、异常心电图的诊断术语与书写层次,并特别提出小儿心电图的诊断要点。此外,本共识还对人工智能辅助诊断的规范化应用及可穿戴设备应用的工作模式进行了展望,旨在为心电图报告书写提供科学、实用的指导规范,全面提升心电图的临床诊断价值。

关键词: 心电图, 报告规范化, 诊断术语, 标准化, 同质化

Abstract: Electrocardiography is one of the most widely used non-invasive techniques for cardiac evaluation in clinical practice. However, substantial variation exists in the format, diagnostic terminology, and structural hierarchy of electrocardiogram(ECG)reports across medical institutions at different levels in China. This phenomenon—often described as “different reports for the same ECG”—poses significant challenges for clinical diagnosis and treatment, medical education, and scientific research. To promote the standardization, normalization, and homogenization of electrocardiogram diagnostic reports in China, the Electrocardiography Branch of Shandong Medical Association orga-nized experts from relevant fields to develop this expert consensus. The consensus was formulated through a comprehensive review of domestic and international literature and guidelines, combined with clinical practice in China. It systema-tically addresses key considerations in electrocardiogram data acquisition, clarifies the basic structure and essential elements of ECG reports, and standardizes diagnostic terminology and hierarchical organization for normal and abnormal electrocardiograms. Particular emphasis is placed on diagnostic features specific to pediatric electrocardiograms. In addition, the consensus discusses the standardized application of artificial intelligence-assisted ECG interpretation and outlines potential working models for wearable device integration. The objective is to provide scientific and practical guidance for electrocardiogram report writing, thereby enhancing the clinical diagnostic value of electrocardiography.

Key words: Electrocardiogram, Standardized reporting, Diagnostic terminology, Normalization, Homogenization

中图分类号:

R540.4+1

山东省医学会心电学分会山东省医学伦理学学会心电学分会. 心电图报告规范化书写专家共识(2026)[J]. 山东大学学报 (医学版), 2026, 64(4): 1-7.

Electrocardiography Branch of Shandong Medical AssociationElectrocardiography Branch of Shandong Society of Medical Ethics. Expert consensus on standardized electrocardiogram reporting(2026)[J]. Journal of Shandong University (Health Sciences), 2026, 64(4): 1-7.

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