Nanyang tuberculosis dispensary

First, the importance of medical record writing

It is an indispensable basis for correctly diagnosing diseases and deciding treatment plans, and it is a basic skill that clinicians must master.

It is an objective evidence of medical management information and medical work quality, and an important material to measure medical level.

It is an important material for clinical scientific research and clinical teaching.

It is the patient's medical record file and the original data of preventive health care.

It is an important legal basis for handling medical disputes and identifying disability.

Second, the basic requirements of medical record writing

Authenticity: truthfully reflect the condition. When asking about medical history, there should be no suggestive and taken for granted views. Systematization: the main symptoms must be collected according to the formal requirements, and the meaningful negative medical history and signs must be described.

Integrity: All data must be collected in sequence.

Timeliness: it should be completed within 24 hours, and the first course of disease should be recorded in time for critically ill and rescued patients, and the rescue treatment should be recorded at any time.

Normality: unified norms, concise words, accurate terminology, simplified words and foreign abbreviations should be written in accordance with national regulations or world practice formats, and may not be created at will.

Cleanliness: the handwriting is neat, and it is forbidden to cut, paste or alter it.

Three, tuberculosis outpatient medical records content and format

Object of establishing medical records: All patients registered for treatment in the tuberculosis patient register should establish medical records.

(a), the first page of medical records

general run of things

Registration number: It is the same as the registration number of patients in the register of pulmonary tuberculosis patients, with six digits. Medical record number: six digits. It can be consistent with the patient's registration number, or it can be equipped with another number as needed. If it is consistent with the patient registration number, it does not need to be filled in and can be empty; If it is inconsistent with the patient registration number, it needs to be filled in. But for the same project unit, the format should be unified.

Address: The first column is the permanent residence and residence, the second column is the floating temporary residence and residence, and the second column for non-floating personnel can be left blank.

Work Unit: No work unit can be empty.

Patient source: tick "√" on the corresponding item.

In the blank space behind this column, fill in the referral unit and referral doctor.

Medical history:

Chief complaint: the main symptoms (or signs) of patients and their duration. No more than twenty words.

Current medical history: including further clarification of the chief complaint; The location, nature, duration, degree, relief mode, development and evolution of the aggravating factors of symptoms; Diagnosis and treatment process and effect; Influence on daily life (changes in diet, sleep, defecation, weight, physical strength, etc.). ).

Past history: general health status, infectious diseases and their contact history, vaccination history, traumatic surgery history, major diseases history, drug allergy history, long-term medication history.

Use history of anti-tuberculosis drugs: The type, dosage and time of drug use should be listed in detail. Brief medical history should include current medical history and previous brief tuberculosis history. A previous history of tuberculosis should not be stated.

Physical examination: blood pressure, pulse, breathing and weight are not allowed to be empty.

Auxiliary inspection:

There is no nullable item in the knot element test. The reasons for not checking sputum smear should be explained.

Diagnosis:

Primary pulmonary tuberculosis (Ⅰ)

Hematogenous disseminated pulmonary tuberculosis (Ⅱ)

Secondary pulmonary tuberculosis (Ⅲ)

Tuberculous pleura (Ⅳ)

Other extrapulmonary tuberculosis (Ⅴ)

Regarding the 8 dates on the home page, no empty items are allowed.

The dates of first symptom, first visit, first diagnosis, first treatment and last treatment are consistent with the time description of the patient's current medical history. Date of diagnosis, date of registration and date of treatment refer to the corresponding date when the patient visited the tuberculosis control institution.

Treatment:

Treatment plan: fill in the corresponding column according to the format required by the national tuberculosis work manual. Project patients must fill in the name of the treatment supervision unit or rural doctor.

Doctor: It is required to sign the full name, and then write down the time to complete the medical record.

Cumulative dose: Cumulative dose includes the sum of previous tuberculosis history dose and current tuberculosis history dose. If anti-tuberculosis treatment has never been performed, the cumulative dose can be empty.

(2), medical records on the second page:

Family contact: fill in the information of the patient's spouse, children and close contacts.

Patient's medication record: fill in the medication type and the number of medication boards.

Examination record of sputum tuberculosis: fill in carefully item by item, with no interval between rows.

(3) medical record continuation page: used to write the course record.

Basic format

Capitalize the date;

The first course record is written in the center;

The specific content is written in two blank spaces, and finally the writer is required to sign his full name.

Record of the first course:

Main contents: briefly describe the chief complaint and current medical history, previous history of anti-tuberculosis drugs, positive signs of physical examination, main examination results such as chest X-ray and sputum smear, collective diagnosis records, diagnosis, treatment plan and review time of patients with negative sputum smear by a diagnosis team composed of at least 3 outpatients and radiologists.

Records at the end of strengthening period:

Main contents: record the changes of symptoms of patients after taking medicine for two months; Whether there are any adverse reactions after medication; Whether the medication is regular, whether there is any drug leakage in the middle, and the reasons for the drug leakage; Main examination results such as chest film and sputum smear; The scheme after the strengthening period is transferred to the continuation period.

Records of the patient in the fifth month:

Main contents: symptom relief after application of continuation scheme; Results of sputum smear examination; Urge patients to review on time; Emphasize the importance of reexamination at the end of treatment.

Summary of medical records at the end of the course of disease

Main contents: briefly describe the diagnosis and treatment process of patients (chief complaint, diagnosis and treatment plan); The treatment results of patients (symptom relief, chest X-ray absorption, sputum negative conversion); Inform the patient that the course of treatment is over and the patient is cured clinically.

Description: The project patients have at least the above four course records; Non-project patients should have at least (1), (2) and (4) course records.

(4) Check the paste sheet: paste it neatly in chronological order.

Including chest X-ray or chest X-ray report

Sputum list

Checklist of blood routine and urine routine

Liver function checklist

PPD experiment sheet

Other list

(5) Responsibility letter for patient management: a management responsibility letter signed with the selected tuberculosis patients.

(six), the county patient project personnel to supervise the patient report:

For each project patient, the county supervisor should visit at least once during the intensive period and the continuation period of the patient, and the supervision report should be returned to the medical record in time after the visit.

(7) Patient medication record card: it is recovered from the grass-roots supervisor at the end of the course of treatment and kept in the medical record file.

Arrangement requirements of tuberculosis standard medical records

1, medical record home page

2, the second page of medical records

3. Continued pages of medical records

Step 4 check the pasted page

5, patient management responsibilities

6, the project patient county supervision report (at the end of the course of treatment should be 2 times)

7, patient medication record card (at the end of the course of treatment by grassroots supervision doctors)

Description: The patient's medical record of the project should have the above seven contents; The medical records of non-project patients should have at least the first four items.

Model essay on writing norms and filling format of standard medical records of tuberculosis patients

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