1. Write in blue or black pen or ballpoint pen in the medical record printing frame; The font is neat, the handwriting is clear, and there are no self-made words or typos; The original handwriting can be recognized by correcting clerical errors with double lines on typos; When reviewing and modifying medical records, the date of modification should be indicated, and the signature of the modifier should be clear and easy to read.
2. Fluent language, correct terminology and correct drawing marks.
13. The name and page number should be recorded in the header of the attached page.
4. Write a medical record according to the initial complaint (chief complaint). Follow-up refers to the continuous treatment of the chief complaint (chief complaint).
5. When mistakes and omissions are found in the medical records, they should be supplemented and explained at the end of the article. It is forbidden to correct mistakes and omissions in the original place.
6. The patient's name and medical record number should be indicated on the tooth pocket.
Second, the medical record home page
1. Record name, gender and age; The filed medical records shall record the telephone number, mailing address, initial diagnosis department, date, postal code, X-ray film number and pathological number.
Drug allergy history indicates allergic drugs or records as "rejected".
The first page of archived medical records should also record the following contents:
3. Diagnosis or preliminary diagnosis: location+diagnosis name.
3. The first page of medical records after each diagnosis and treatment should indicate the date, subjects, diagnosis, treatment and doctor's signature.
Third, the chief complaint
1. location+symptoms+onset time (or course date)
3. Some chief complaints may not include symptoms or onset time (such as asking for repairing missing teeth or pulling out residual roots).
3. Follow-up visit: Write down the symptoms of the same tooth or disease after treatment.
Fourth, the current medical history
The occurrence, development, past treatment and present situation of the history of complaining teeth (complaining diseases).
Five, past history, family history, general situation (medical record manual can be combined with other items or omitted)
1. Record the patient's statement correctly (related to this disease).
2. Pay attention to the situation when there is no statement.
Six, check
Dental pulp major, oral pediatrics major
1. Dental caries, dental pulp and apical diseases.
(1) The tooth position of the chief complaint tooth or the tooth position consistent with the chief complaint and symptoms, decayed tooth surface, decayed degree, probing, percussion and looseness.
⑵ X-ray radiographers should correctly describe root resorption, periapical circumference, root bifurcation, permanent tooth germ, etc.
⑶ Correctly record the abnormal conditions such as tooth position, decayed tooth surface and so on of non-chief complaint teeth suspected to have lesions.
⑷ The results of pulp vitality test when necessary.
5] Correctly record the periodontal conditions and other situations related to the chief complaint.
2 Follow-up visit: record the reaction of the chief complaint tooth (chief complaint disease) after the last treatment and the findings of this examination in detail. Inspection items shall be recorded. If it is not recorded in the inspection items, it will be regarded as a negative result.
Periodontal specialty
1. Correct records;
Dental calculus, calculus degree, gingival tissue changes, periodontal probing, tooth loosening, occlusal trauma, dentition defect, etc.
4. Patients receiving periodontal system treatment should fill in the periodontal expert checklist in detail:
Probe depth, gingival recession, bleeding index, loosening, dental calculus, furcation lesion, jaw relationship, plaque index, signature date, treatment design.
3. Correctly record the X-ray and other auxiliary inspection findings.
2. Correctly record other positive findings of oral cavity, extraoral cavity, prosthesis and orthodontics or no record of the above situation.
5. Follow up and record the reaction after the last treatment and the results of this examination in detail.
Mucosal specialty
1. Record correctly.
(1) location, size, nature, surface and basement of mucosal tissue.
⑵ Skin and general situation related to mucosal specialty.
2. Correctly record the necessary blood tests, smears and biopsies.
3. Record the reaction after the last treatment and the findings of this examination in detail.
oral surgery
1. Record the chief complaint tooth to be extracted in detail:
Loose teeth, dental caries, periodontal manifestations and trauma.
2. Correctly record the positive results of oral surgery of adjacent teeth, other non-main teeth and relative dentition.
3. Oral and maxillofacial trauma.
(1) Injury, injury, blood loss and general situation.
⑵ Record the vital signs (T, P, R, BP) of the emergency patients.
4. Joint diseases, inflammation and tumors.
(1) Record the oral cavity, maxillofacial region, lip and tongue, buccal mucosa, lymph nodes and general conditions of the whole body in detail.
⑵ Opening degree, opening type, chewing, joint tenderness point, joint snapping, occlusal function, etc.
5. Correctly record X-rays, examinations, pathology and other auxiliary examinations.
6. Record other positive results correctly.
Follow-up: record the reaction after the last treatment and the findings of this examination in detail.
Orthodontic specialty
1. Complete the normal program writing of the first page of medical records, and fill in "See Orthodontic Medical Records for details" in the check box.
2. Record orthodontic medical records in detail (excluding joint disease orthodontics, surgical orthodontics and periodontal orthodontics).
(1) Name, gender, age, date of birth, native place, height and weight, medical record number, record number, X-ray number, doctor, and start date of treatment.
⑵ Fill in the general oral information as required.
⑶ Correctly describe what orthodontists see:
Type and Moore relation. When there is no positive finding, such as overbite, overbite, opening and closing of front teeth, crowded dentition, malocclusion, midline, jaw, alveolar socket, facial health, joint condition, family history, diagnosis and factor mechanism, etc., "-"should be recorded.
(4) Correctly describe and record the X-ray inspection results.
13. Follow-up visit: record the situation after the last treatment and the findings of this examination in detail.
Repair specialty
1. Correctly record the discovery of tooth defects.
Abutment position, shape, defect, treatment (treatment of pulp and unmyelinated teeth), looseness, gum, periodontal pocket and occlusal relationship.
2. Correctly record the discovery of dentition defect.
The location and number of defects, occlusal relationship and the health status of the remaining teeth.
3. Record the missing dentition correctly.
(1) alveolar bone condition, mucosa, tooth extraction wound, bone cusp process.
(2) Normal occlusion, deep overlap, deep coverage, butt joint, reverse closure, locking and offset.
⑶ Vertical distance, temporomandibular joint and oral mucosa.
X-ray manifestations: dental caries, periodontal ligament, periapical, alveolar bone, root filling, etc.
⒌ Correctly record the positive orthodontic findings of non-chief complaint (chief complaint).
6. Correctly record other oral and extraoral positive findings or no such records.
Follow-up visit: the shape, retention, edge extension, cohesion, occlusion, beauty and repair effect of the prosthesis after treatment.
Seven, diagnosis
The diagnosis basis is sufficient and the diagnosis name is correct.
(1) Diagnosis of chief complaint tooth (chief complaint disease).
(2) Diagnosis of other diseases.
If the diagnosis is not clear, the "impression" or "to be investigated" should be recorded.
3. If you still can't be diagnosed after three visits, please consult your superior doctor in time and make detailed records.
Eight. deal with
1. Treatment design
(1) Simple design scheme.
Obtain the consent of the patient or his guardian.
⑵ The treatment design is reasonable, and charts shall be attached when necessary.
⑶ The design of orthodontic treatment should record the requirements of patients or parents of children and the purpose of treatment in detail; Design drawing, date and signature of movable orthosis.
⑶ Record the treatment design in detail in professional medical records.
4. Clinical technical operation
(1) Record the treatment process, operation, medication and operation in detail (record the number, position, length, pulp state and crown pulp of root canals).
⑵ Complete the treatment process according to the quality control index.
(3) When the treatment of difficult diseases exceeds the course of treatment, the superior doctor should be consulted in time and recorded in detail, and the consultant should fill in the consultation opinion when necessary.
(4) Determine the follow-up date after the designated chief complaint tooth or stage of treatment.
3. Clinical medication
Record the drug name, dosage and usage in detail, and use the drug reasonably and correctly.
Nine. sign
The attending physician and the guiding physician should sign their full names in clear handwriting.