The course record is the record of the patient's course after admission, which reflects the evolution of the disease and the process of diagnosis and treatment in detail, and is an important part of the medical record.
(a) the first course of disease records
1. The first course record should roughly describe the patient's chief complaint, main symptoms, signs, examination results, etc., and should not be the same as the admission record, and put forward a preliminary diagnosis or diagnostic analysis to make the next diagnosis and treatment plan.
2. Diagnostic analysis
Summarize, analyze and discuss the main symptoms, physical examination findings and examination results, and briefly put forward the reasons for the proposed diagnosis and the main differential diagnosis. clarify a diagnosis
You can list the diagnosis basis. The diagnosis basis should be sufficient. When there are multiple diagnoses, analyze them one by one. The diagnosis basis is arranged in order.
3. Diagnosis and treatment plan
According to the diagnosis or preliminary diagnosis, the items and specific completion time of the progressive examination should be determined, such as "liver function and renal function examination should be completed before April 1 2002", and general words such as "symptomatic treatment, preoperative preparation and elective surgery" should not be used. In terms of treatment, the treatment principles of major diseases are expounded first, and then specific treatment measures are written according to the principles. When taking medicine, the specific drug name, dosage, usage and course of treatment are written. For surgical inpatients undergoing elective surgery, it is necessary to write down the name of the operation to be performed, what preoperative preparations need to be made, pay attention to whether there are any surgical contraindications, and suggest what anesthesia to use if necessary. The superior doctor must personally approve the plan and supervise its implementation.
4. The newly admitted difficult critically ill patients should be checked immediately, and report to the superior doctor for tertiary examination. For the average patient, the superior doctor must check within 24 hours.
Diagnosis. The first visit record should record the analysis and diagnosis and treatment opinions of the superior doctor in detail, with specific contents and the name and technical position of the superior doctor, and cannot be vaguely recorded as "the superior doctor has seen the patient"
5 The attending physician and above should indicate the technical position or administrative position when checking and writing the records of the first visit, such as "Attending physician: Xiao Xu". Generally, the first course record of a patient does not need to be written by a superior doctor, but there should be a ward round record of the department director within one week.
(2) General course records
General course records mainly record the patient's condition changes and diagnosis and treatment after admission, which are written by residents or interns in chronological order.
1. The patient's current chief complaint, illness change, physical examination and important findings, illness analysis, diagnosis and treatment.
2. Preliminary analysis and treatment of puncture process, sampling and test results.
3. such as cardiac catheterization, radiofrequency ablation, electric defibrillation,
Operation process and results of treatment and endoscopic retrograde cholangiopancreatography.
4. The chief physician, attending physician and other superior doctors' rounds or consultation opinions are important contents of clinical teaching and should be recorded in detail and accurately.
5. The special examination results of patients, such as blood biochemistry, water, electrolyte, blood gas analysis, immunological indexes, electrocardiogram, ultrasound results, etc., should be analyzed and processed in time in combination with clinical conditions, and their corrections should be recorded at any time.
6. Records of all diagnosis and treatment operations, operation records of relevant operation departments, postoperative course records, etc.
7. For long-term hospitalized patients, write a stage summary once a month, including the current condition changes and diagnosis and treatment, the patient's current situation and future diagnosis and treatment plan, and modify the diagnosis and treatment plan when necessary.
8. Consultation opinions of other departments or other hospitals, determination of new diagnosis or modification of original diagnosis and its basis.
9 important instructions of the administrative leadership, the reflection or request of family members and relevant personnel, and the conversation with family members or unit personnel.
10. Other records in the course of disease, such as consultation records, case discussion records, operation records, handover records, professional change records, discharge records, etc.
1 1. When the patient leaves the hospital, write a discharge summary, summarizing the evolution of the disease after admission, the process and effect of diagnosis and treatment, and the situation at discharge, and finally make diagnosis and guidance. Write rescue records, death summary and death discussion when the patient dies, and sum up experiences and lessons. For patients who change their major (hospital), write the record of changing their major (hospital).
(3) Matters needing attention in writing course records
1. The course record should be written on a new page. The "course record" is located in the center of the medical record paper, and the left side indicates the year, month and day (when necessary, record the hours and minutes).
2. The course record is written by the resident or the doctor on duty. When there are interns and senior doctors, they will write for them. The teaching doctor or superior doctor should check it in time.
Check, make necessary amendments and supplements, and sign the full name.
3. Don't run a running course or a tedious course without focus.
Records should be timely, continuous, comprehensive, accurate and scientific.
First of all, the record should be timely. Critical rescue cases should be recorded at any time and marked with specific time. The off-duty time is recorded by the doctor on duty, at least once a day for severe patients, once every three days for general cases, and the longest interval for stable or chronic cases is no more than five days. Record at least once a day for 3 days after major and secondary operations, and then determine the interval recording time according to the condition. Consultation records, operation records, special examination records and special treatment records cannot be used as course records to calculate the interval time.
The second is to pay attention to the continuity of illness records. For example, the positive symptoms and signs at admission, when to reduce or disappear, should be reflected in the course record.
Third, we should pay attention to the comprehensiveness of course records. The above course records should contain 1 1 and need to be carefully covered.
Fourth, the content of the record should be accurate. If blood pressure drops and white blood cells rise, it is necessary to have an exact value to avoid specious ambiguity.
Fifth, we should pay attention to the scientific nature of course records. The course record should generally conform to the evolution law of the disease.
(4) the format of brain course record
L the first course record
Highest fairway record
Year, month, day, hour and minute
Main symptoms, signs and related examinations
diagnostic analysis
Diagnosis and treatment plan
Physical examination of superior doctor
Doctor's signature
2. General course records
Year, month and day
Briefly describe the changes of illness, treatment effect and the main points of illness of superior doctors on the same day or in recent days.
Analysis and diagnosis and treatment opinions, relevant inspection results and medical care precautions.
Doctor's signature
(5) course record demonstration
1. First demonstration of course record
Highest fairway record
20** a 2 a 4 10:20
Patient Wang Moumou, female, 19 years old, student. Due to intermittent fever, joint pain of limbs 16 months, he was admitted to the hospital on the morning of February 4th, 2010 10.20.
In the past year and a half, patients often have irregular fever and hyperhidrosis, sometimes their body temperature is as high as 39℃ or above, accompanied by wandering swelling and pain of limbs. Taking antipyretic and analgesic drugs is temporarily effective, and the above symptoms have worsened in the past month and have been hospitalized. Physical examination: temperature 37.5℃, pulse 94/min, blood pressure 120/85mmRg. Chronic disease, clear-headed, independent.
Body posture. Pharyngeal congestion is mild, tonsil II is swollen, and there is no purulent secretion. The heart boundary is normal, the heart rate is 94 beats/min, the rhythm is regular, the first heart sound in the apical area is low and dull, and the systolic murmur of Grade II blowing can be heard, but it is not conductive, A2 and P2. There's nothing abnormal in the lungs and abdomen. There is no abnormality in joint movement of limbs. A number of nodules with a diameter of about 3 -5 mm can be touched under the elbow joint, forearm extension and anterior tibia, which are hard, unconnected with the skin and slightly tender. Bilateral wrist joints and stomping joints are swollen, and the knuckles are normal. Laboratory examination:
Erythrocyte 3.4x 10' 2/L, HBLLOG/L, leucocyte 7. 1 0, /L, N28%, L72%, ESR 60mm/h, ASO 1:2000+. ECG showed ① sinus rhythm; ②ST segment: II, AVF, V3-v5 moved down by 0.05-0. 075mV, accompanied by low t wave.
Diagnostic analysis: Basis: ① The patient is a young woman; The drama is intermittent fever with joint pain of limbs; ③ There are subcutaneous nodules near the joints of limbs; ④ The first heart sound is low and dull, and non-conductive systolic murmurs are heard in the apical region; ⑤ ESR increased rapidly, and the ECG showed sr-T changes. Diagnosis: rheumatic fever (active stage).
Diagnosis and treatment plan: ① bed rest, soft food, temperature measurement 4 times a day; ② Penicillin 800,000 units, intramuscular injection twice a day to control streptococcal infection; ③ Anti-rheumatic treatment is not needed for the time being, so check and observe first; ④ Check liver function, immunoglobulin, rheumatoid factor, antinuclear antibody, E rosette test, lupus cells, etc. Exclude other connective tissue diseases; ⑥ Subcutaneous nodule biopsy.
Attending physician Zhao examined the patient in the morning and agreed with the diagnosis of rheumatic fever (active stage). * * * made a diagnosis and treatment plan together, and charged: ① closely observe the changes of the disease; ② Complete all inspections as soon as possible.
Li moumou
2. General course record demonstration
20** A 2 and a 6.
The patient was hospitalized for two days and his condition was stable. He still has a low fever (37.5℃ -38t), and the joint swelling and pain are not aggravated. This morning, Dr. Wang made rounds. After listening to the medical history report and physical examination, he thought that according to the patient's manifestations of wandering swelling and pain in the big joints, subcutaneous nodules, accelerated ESR and ST-T changes in electrocardiogram, combined with the above other laboratory differential examinations,
They are all negative, and connective tissue diseases, such as rheumatoid arthritis and systemic lupus erythematosus, can be ruled out. Agree with the original diagnosis and treatment plan. Instruct to start using anti-rheumatic drugs, take aspirin 0 first. 9g orally, three times a day, and pay attention to the digestive tract reaction. If you have high fever, you can use prednisone 10mg three times a day. In view of the multiple nodules under the skin, 24-hour urine acid quantification and arthrography are required to rule out gout. Anti-rheumatic treatment has been started, and the changes of the condition should be closely observed. Follow the instructions above.
Li moumou