Daily course record

1. Structure of daily course records

Generally, the first paragraph records the date, the second paragraph records the course of disease, and finally signs it.

2. Contents of daily course records

(1) The patient's self-conscious symptoms, illness changes, mental state, sleep, diet, defecation, etc., as well as the illness changes, the appearance of new symptoms, the change of signs and the occurrence of complications.

(2) Analysis and judgment of new auxiliary inspection and special inspection results.

(3) the process of special diagnosis and treatment operation, the effect and response of treatment.

(4) Requirements and opinions of patients or their relatives and friends.

(5) personal analysis of patients' condition, opinions of superior doctors on diagnosis and treatment, and consultation opinions.

(6) important doctor's advice changes and their reasons, and the reasons for supplementing or changing the diagnosis and treatment measures.

(7) future diagnosis and treatment opinions and plans.

3. Writing requirements of daily course records

(1) Daily course records are generally written once a day or every other day; The interval of course recording of patients with chronic diseases can be appropriately extended, but at least 1-2 times a week; Critical patients or patients with sudden changes in their condition should be recorded at any time. (1) In general, the course records of patients in new hospitals should be recorded three times in a row.

(2) Daily course records can be compiled by advanced doctors, interns and residents. However, the course records written by senior doctors and interns without prescription rights should be revised and signed by higher-level doctors in time.

(3) It must be written around the characteristics and development of the patient's disease, which can reflect the observation point and diagnosis and treatment characteristics of the case, have a clear three-level ward round record, record the name and technical title of the superior doctor, and make suggestions and basis for diagnosis or further examination and treatment after seeing the patient. Other instructions of the superior doctor about this case should be summarized and recorded, and marked with quotation marks. The implementation and effect or result of the instructions of the superior doctor should be truthfully recorded.

(4) To seek truth from facts when writing the course record, record the improvement of the condition and record the deterioration of the condition in time; Successful experience should be recorded, as well as mistakes and mistakes in work.

Highest fairway record

20xx。 xx。 xx。 Xx morning

Today, attending physician xxx made rounds and looked at the medical records, thinking: "According to the results of outpatient examination, this case can be definitely diagnosed as' acute lymphoblastic leukemia'. The patient has obvious bleeding tendency, and internal bleeding cannot be ruled out. Although it is not acute myeloid leukemia, DIC may occur, so you should contact the laboratory for DIC examination. At present, the focus is on anti-infection, hemostasis and chemotherapy. VIP regimen (vincristine and prednisone) can be selected for chemotherapy, and the treatment scheme will be further adjusted after DIC examination is clear. " The instructions of xxx attending physician have been carried out.

Doctor's signature: xxx