1) All kinds of notices should be timely, accurate and complete after admission. This is an important part of preventing all kinds of medical disputes.
2) Death discussion records should be carefully discussed and written, and cannot go through the motions. Only in this way can we learn from experience and make continuous improvement, especially the cause of death should be carefully analyzed, and the director of the department should listen to the opinions of doctors at all levels. The discussion will be completed within 7 days, reviewed and signed by the department head.
3) The discharge orders should be specific, not generalized, such as continuing anti-inflammatory treatment, dressing change when necessary, chemotherapy and other vague language. It is necessary to have the name, quantity, usage and time of the drug, and when to come to the hospital for chemotherapy or stitches after discharge. If you don't write, there may be disputes between doctors and patients.
4) During hospitalization, any patient should have at least one ward round record of the department director, even if the patient is managed by the attending physician or deputy chief physician, or the patient is only hospitalized for a few days.
5) The first page of medical records should be written in strict accordance with the requirements of the Health Planning Commission, and the items should be filled in completely. As usual, telephone number, address, external factors of injury and poisoning, name of hospital infection, diagnostic compliance, operation code, age and occupation were omitted. The discharge record should be consistent with the diagnosis on the first page of the medical record, and the outcome should be true.
6) All kinds of signatures should not be written by others, but should be signed by the doctor himself.
7) All modifications shall be made according to the requirements of the Health Planning Commission, and scraping is not allowed.
The expanded data include the main symptoms and their development and changes, the changes in diagnosis, treatment, sleep and diet after symptoms appear, and positive or negative data related to differential diagnosis.
The past medical history cannot be omitted, with emphasis on the history of blood transfusion, drug allergy, infectious diseases, surgery and trauma. Asking about medical history should be carried out item by item according to the system.
Physical examination should be carried out carefully and written according to the requirements of diagnostic admission records. The key points are temperature, pulse, respiration, blood pressure, consciousness, pupil size, whether the sclera is yellow, how the corneal reflex is, whether the skin has bleeding spots, spider nevus, ecchymosis, yellow staining and so on.
Whether there is a sense of resistance in the neck, whether the jugular vein is full, whether there is sound in both lungs, whether there is any murmur and conduction in the heart, whether there is consolidation in the chest percussion, and the examination of the abdomen, with emphasis on bowel sounds and voiced sounds, whether there is tenderness and rebound pain in the abdominal wall, and whether there is a lump.