1. objective and true.
First of all, objective truth means that the content of description needs to summarize objective facts. In fact, the daily vernacular used by patients to describe symptoms in clinical practice is not a standard medical language. Even if medical terms are used, it does not mean that patients understand the meaning.
The most typical case is the so-called "syncope cause" patient. The first step of diagnostic thinking is always to know whether you are syncope, and the objective description of symptoms here needs to be defined by the doctor who writes his own medical records. Patients cannot be expected to understand the difference between dizziness, dizziness and syncope. Another example is diarrhea. Patients may not know what diarrhea is. He tells you that he has diarrhea, and the doctor needs to summarize it by asking. Is it really diarrhea or bloody stool? Further inquiries are needed, such as frequency, water content, mucus, purulent blood, undigested food, color and so on.
When asking patients, you need to use daily language that can communicate with different patients, and when it comes to writing, it must be communication between peers, written language and format.
On the other hand, objectivity means that facts cannot be misinterpreted. It is easy to happen that when a junior doctor or intern asks about his medical history, the patient answers, assuming he understands what he means, while other doctors (often superiors) ask for another result. A simple way to ensure objectivity and truthfulness is for the patient to describe a medical history and simply repeat it to confirm whether there is any problem with his understanding.
Another very common non-objective situation is that when writing a medical record, the current medical history is omitted, and then fabricated for fear of losing the trust of the patient or being considered a rookie by nurses and superiors, especially when describing negative symptoms, always trying to avoid being mistaken. But in fact, this is one of the reasons why it is most easily cultivated by serious superior doctors.
Step 2 be specific and detailed
This affects every link. Take diarrhea as an example. In addition to being clear about diarrhea, you should continue to ask if you have abdominal pain, nausea and vomiting. Are you motivated to ask how it happened? How did it develop? Can it be relieved by itself? Have you received treatment? Do you have a fever? Are you dizzy? Wait a minute. When writing a case, it is of great significance to ask the clinic for information in detail for diagnosis and differential diagnosis. Don't believe it. Look at this one below.
Take chest pain as an example. Chest pain is a common symptom of heart disease. In the cardiology ward, all the patients admitted to the hospital for outpatient screening are coronary heart disease. Many interns and residents have no problem asking detailed questions in the ward. They naturally don't think there is anything wrong with the lack of detailed medical records, but they all show their true colors as soon as they arrive at the emergency room.
The diagnosis of coronary heart disease can rely entirely on the medical history, and asking questions is the basic skill. There are many descriptions about the location and nature of pain, but the regularity of attack, the characteristics of relief and the time change of symptoms all affect the judgment of the cause, but it is easy to be missed. If you forget these things, you will naturally encounter herpes zoster and chest muscle strain in clinic, which is easy to be misdiagnosed.
In addition, even with coronary heart disease, the frequency and duration of the attack directly affect the final diagnosis and risk stratification. It is even worse in rheumatology immunology department, and any omission of accompanying symptoms may lead to the correction of disease diagnosis. It is safe to follow the medical record template of the textbook, but if you don't understand the truth and make mistakes, you will eventually become lazier and lazier, and your clinical knowledge will be solid enough to know the meaning of every detail you ask and write.
The medicine is the same. First of all, the reaction to therapeutic drugs is an important basis for disease diagnosis, such as annoying tuberculosis; Then it is necessary to judge the patient's condition, especially the patients with nephrotic syndrome and autoimmune diseases. The treatment response of glucocorticoid, the events in the reduction process and the response to immunosuppressants used are very important for drug selection after admission.
Finally, each subject has contents beyond the standard template, which need to be supplemented by every doctor and medical student who writes medical records to ensure the success of each subject. For example, the related contents of endocrine complications of DM, autonomic complications of peripheral nerves, description of joints in rheumatology and immunology, and inquiries about related symptoms of patients with secondary hypertension.
3. Very delicate
There are too many medical records in the running account, which is simply torture for readers. It is necessary to find the key points in the medical records line by line.
Sometimes just complaining can tell others what's wrong with the patient and how long it has been. Such as repeated expectoration and wheezing for 15 years, aggravating with shortness of breath for 2 days. This is the main complaint. The main complaint must be concise, and the punctuation should not exceed ... >>
Question 2: How to write the medical records of complete cases? Including the first medical record, admission record, discharge record, course record, operation record, etc. Medical record writing refers to the behavior of medical staff to obtain relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, treatment and nursing, and to summarize, analyze and sort out the records of medical activities. The writing of medical records should be objective, true, accurate, timely and complete. Inpatient medical records should be written in blue-black ink and carbon ink, and outpatient (emergency) medical records and materials can be copied with blue or black oil-water ballpoint pen. Medical record writing should be neat, clear, accurate, fluent and punctuated correctly. When typos appear in the writing process, they should be marked with double lines, and the original handwriting should not be covered or removed by scraping, gluing or painting. Medical records written by interns and trainee medical personnel shall be reviewed, revised and signed by medical personnel who are legally practicing in this medical institution.
Question 3: How to inquire about personal medical records? You can ask the doctor who treated you first, and ask him to help you write an application to the hospital medical record room and make a copy of your medical record. This is relatively simple. Usually, the doctor will give it to you when it is ready. Just wait for it yourself. Another way is to go to the medical record room of the hospital yourself, retrieve your case according to your case number (or medical record number) when you were hospitalized, and print it out in the medical record room to take away. You have to pat your legs yourself.
Question 4: How to write fake medical records is divided into inpatient medical records and outpatient medical records. I wonder which one you want to write. If it is an outpatient medical record, it will be simple. Just find a friend who is studying medicine and go to the hospital to buy a medical record to write. If you have passed the hospitalization record, I advise you not to do it. It's impossible. If you don't believe me, you'll know once.