ask
The cover of the medical record should clearly fill in the patient's name, gender, age, native place, occupation and address, and the age should not be written as "Cheng". If it is a new disease, it should be written according to the format of the newly diagnosed medical record; If it is a follow-up visit to an old disease, it should be written in the format of the follow-up medical record. The medical history and physical examination requirements of the newly diagnosed patients are more comprehensive, so as to make reference for the follow-up visit. Outpatient medical records should be filled out by the attending physician at the time of the patient's visit.
format
1. Initial diagnostic format:
* family, * year * month * day.
Main complaints:
Current disease history
Past medical history, personal history, family history, etc. (A brief record of the medical history related to the disease or other meaningful medical history is required)
Physical examination: (mainly record positive signs and meaningful negative signs)
Laboratory test results
Special inspection results
tentative diagnosis
Handling and suggestions: (1)
(2)
Signature of doctor: ××××××
2. Subsequent format:
* family, * year * month * day.
Medical history: (1) After the last diagnosis and treatment.
(2) the result of the last recommended inspection
Physical examination: (mainly record the changes of positive signs and the discovery of new positive body films)
Laboratory examination and other special examination results
Preliminary diagnosis: (If the diagnosis has not changed, there is no need to write a diagnosis; If the diagnosis changes, it should be rewritten. )
Handling and suggestions: (1)
(2)
Signature of doctor: ××××××
3. See the attached page for the cover of outpatient medical records.
example
Example of initial diagnosis
Internal medicine:1March 20, 994
Paroxysmal cough for half a month.
I began to cough after catching a cold half a month ago, showing paroxysmal and fearless cold and fever, without hemoptysis and chest pain, accompanied by a small amount of white phlegm. I ate cough syrup for three days, and the effect was not good.
I have a history of chronic cough 10 years and have been diagnosed as "chronic bronchitis". I don't smoke. Deny the history of tuberculosis.
Physical examination: blood pressure 128/80mmHg, no dyspnea, no cyanosis in the mouth and lips, no dry sound in both lungs, 90 beats/min heart rate, regular rhythm, no murmur, flat and soft abdomen, no tenderness, no touch in the liver and spleen, no edema in both lower limbs.
Blood routine: HB 120g/L, WBC11.0×109/L, N 0.8, L 0.2.
Initial diagnosis: acute attack of chronic bronchitis.
Treatment: (1) chest film
(2) josamycin 0.2 t.i.d×3.
(3) Compound Glycyrrhiza syrup 10mL three times a day ×3.
Signature of doctor: ××××××
Follow-up example
Internal medicine: 65438+March 25th 0994
After the above treatment, the cough was slightly relieved and no expectoration was found.
Physical examination: Generally speaking, there is no dry and wet sound in both lungs.
Chest X-ray: The texture of both lungs is thickened, there is no subjective lesion, and the heart shadow is normal.
Treatment: (1) compound licorice syrup 10Ml three times a day ×3.
(2) josamycin 0.2 t.i.d×3.
Signature of doctor: ××××××
Question 2: How to write the medical record of gastritis? Chief complaint: Repeated abdominal distension and abdominal pain for half a year, aggravated 1 week.
Current medical history: Six months ago, the patient had abdominal distension and abdominal pain without obvious reasons, which occurred more than half an hour after meals, accompanied by nausea and vomiting. The vomit is stomach contents, without fever, diarrhea, chest tightness, chest pain, dyspnea, etc. For more than a week, my symptoms gradually worsened. I took anti-inflammatory drugs at home (the specific situation is unknown), but my symptoms did not ease, so I came to our hospital for treatment one by one. The outpatient department received hospitalization for chronic gastritis.
Since the onset, the patient has a good spirit, normal urination, poor appetite and no obvious change in weight.
Past medical history: no history of trauma surgery, blood transfusion, drug and food allergy.
It's basically the same as this. If the clinics are basically like this, it's almost the same. You just need to make up a little physical examination and medication. If you are hospitalized, you need to add a lot.
Question 3: How to write a medical record 200 points Section 1 General requirements and precautions for medical record writing
1. The admission records of newly admitted patients are carefully written by residents. If there are interns, in addition to the admission records, the intern system will be written into the hospital medical records. Admission records cannot replace admission records. In the process of medical history inquiry and physical examination, residents should guide interns.
2. Admission medical records and admission records should be written after comprehensive analysis and processing after taking medical history and physical examination. All contents and figures must be reliable, concise and to the point, avoiding vagueness, generality and subjective assumptions; Positive findings should be described in detail, and negative materials with differential diagnostic value should also be included. Symptoms and signs should be recorded in medical terms, not in diagnostic terms. If the patient mentions that the patient's disease has not been diagnosed before, put the name of the disease in quotation marks. For diseases related to this disease, the symptoms and diagnosis and treatment should be indicated. The date (or age) and place of occurrence of various facts should be as clear as possible, and the onset time of acute diseases should be inquired in detail.
3. Admission medical records and admission records, in addition to focusing on medical history, signs, laboratory tests and other inspection results closely related to the specialist, we should also pay attention to the records of patients' non-undergraduate injuries and treatment. All unhealed injuries, regardless of long-term medical history, should be included in the current medical history; Only those who have recovered or have not relapsed for a long time can be included in the past medical history. In the diagnosis, we should also list the names of the injuries that currently exist and are still recovering.
Patients transferred or readmitted to other hospitals should be regarded as newly admitted patients. Those transferred from other departments should be written in. Those transferred from different wards or wards of the undergraduate course only need to make necessary records and supplements in the course record.
4. Admission medical records and admission records should be completed as far as possible before the attending physician rounds the next morning, and should be completed within 24 hours after the patient is admitted to the hospital at the latest. If the patient is seriously ill and cannot complete the medical record within 24 hours, a detailed course record must be completed in time; When circumstances permit, the admission medical records can be supplemented. When the number of people admitted to the hospital is large, the time for completing the medical record shall be stipulated by the chief physician as appropriate.
5. Except for obstetrics and a large number of patients with similar diseases admitted to hospital, tables should not be used instead of medical records; If it is necessary to use tabular medical records, it must be approved by the dean.
6. The names and numbers of disease diagnosis and operation shall be based on the International Classification of Disease Names published by the International Health Organization (latest edition), which is convenient for statistics and analysis. The English-Chinese Medical Vocabulary (published by People's Medical Publishing House) shall prevail for the time being. If the names of diseases and individual nouns have not been properly translated, the original text or Latin can be used.
Question 4: Who knows how to write the case of dysmenorrhea? The standard one is the one in the case book. Thank you. Chief complaint: abdominal pain.
Past history: The patient had sudden abdominal pain without obvious inducement.
Past history: dysmenorrhea for many years
Physical examination: there is no tenderness and rebound pain in the abdomen.
Diagnosis: dysmenorrhea
Disposal: hot compress, bed rest, motherwort.
Question 5: 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 6: How to write the same medical record summary as the local medical unit?