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What does the first course record include? How to write?
The first visit record refers to the first visit record written by the attending physician or the doctor on duty after the patient is admitted to the hospital, which should be completed within 8 hours after the patient is admitted to the hospital. The contents of the first diagnosis record include the characteristics of the case, the discussion of the proposed diagnosis (diagnosis basis and differential diagnosis), the diagnosis and treatment plan, etc.

1. Case characteristics: The characteristics of this case should be written after comprehensive analysis, induction, collation of medical history, physical examination and auxiliary examination, including positive findings and negative symptoms and signs with differential diagnosis significance.

2. Quasi-diagnosis discussion (diagnosis basis and differential diagnosis): according to the characteristics of the case, put forward the preliminary diagnosis and diagnosis basis; Write differential diagnosis and analyze unknown diagnosis; And analyze the next diagnosis and treatment measures.

3, diagnosis and treatment plan: put forward specific examination and treatment measures.

Extended data

Daily course record refers to the regular and continuous record of the diagnosis and treatment process of patients during hospitalization. Written by the attending physician, but also by the internship or trainee medical staff, but should be signed by the attending physician. When writing the daily course record, first indicate the recording time, and write another line for the specific content.

For critically ill patients, the course of the disease should be recorded at any time according to the change of the condition, at least/kloc-0 times a day, and the recording time should be specific to minutes. For critically ill patients, the course of disease should be recorded at least once every 2 days. For patients with stable condition, the course of disease should be recorded at least once every 3 days.

Baidu Encyclopedia-Basic Specification for Medical Record Writing

Baidu Encyclopedia-Lesson 1 Record