(a), there is a big medical record, each medical record page should fill in the name and medical record number.
(2), outpatient medical records should be written in blue-black pen or ballpoint pen, the handwriting should be clear and neat, and shall not be altered.
(3) Require patients to write outpatient medical records every time they see a doctor. The first medical record requires the first visit to a certain department; Outpatient follow-up, follow-up, and drug taking records should meet the requirements of follow-up medical records.
(4) The medical record of the first visit should include: date, client, chief complaint, present medical history and past history; All kinds of positive signs and important negative signs, diagnosis or impression diagnosis, treatment advice, doctor's signature. Use words concisely. Need medical terminology.
(5) All kinds of inspection application forms and laboratory tests shall be filled out item by item as required. Become? ), legible,
And record the examination items and results in the medical record.
(6) The diagnosis certificate and sick leave certificate should be copied and recorded in the medical records.
(seven), outpatient patients such as three times can't be diagnosed, the attending physician should put forward the superior consultation, or outpatient consultation discussion, or income hospitalization, solve the problem of diagnosis and treatment as soon as possible. The examination process or instructions of the superior doctor shall be recorded in the medical record for all matters that are handled by the superior doctor.
(eight), the patient or his family's illness related matters must be recorded.
(9) When outpatients need invasive examination or surgical treatment, patients and their families should sign the informed consent card.
(ten), Chinese medicine prescription name must indicate the total amount and the dosage and usage of each tablet (branch). The prescription should be consistent with the doctor's advice in the medical record.
Second, the basic wooden format of outpatient medical record writing
(a), treatment date, department.
(2) Chief complaint:
(2) current medical history;
(4) Past medical history:
(5), physical examination and specialist information:
(6), auxiliary inspection results:
(7) Write diagnosis or impression diagnosis at the bottom right of the medical record.
(eight), diagnosis and treatment advice;
(9) doctor's signature.
Third, the first medical record requirements
(1) General items: the patient's year, month, day (according to the specific time of illness record), subject, gender and age should be filled in.
(2) Chief complaint: the main symptoms and duration of the patient's visit. Need improvement.
(3) Past history: comprehensively record the main medical history of the patient. The contents should include: the incidence, characteristics and evolution of main symptoms and signs, accompanying symptoms, diagnosis and treatment in other hospitals since the onset and results. Why did you come to the clinic? It is required to highlight key points and characteristics.
(4) Past history: record the diseases of various systems related to this disease.
(5) Physical examination: general conditions, blood pressure, superficial lymph nodes, heart, lung, liver and spleen can be exemplified. The routine physical examination related to the chief complaint cannot be omitted.
(6), diagnosis:
1, the writing of clinical diagnosis, the full name of traditional Chinese medicine diagnosis and the specific clinical pathological classification should be written.
2. If the diagnosis is not clear, the symptom diagnosis should be written, and the possibility diagnosis that should be considered first in clinic should be written below.
(7), handling opinions:
1, recording various laboratory tests and image inspection items;
2, record the various treatment measures taken;
3, the prescription should have the drug name, total dosage and usage;
4. When issuing diagnosis certificates and other medical certificates, the contents shall be copied and recorded in the medical records;
5, record the patient's important matters needing attention.
6. If the illness requires timely consultation, the doctor in the consultation department will immediately write the examination and treatment opinions after consultation in the medical record.
(eight), the doctor's signature, requiring the doctor to sign out the full name that can be recognized.
Four, follow-up medical records requirements
(1) General items: date of visit and subjects.
(2) Chief complaint: a brief chief complaint. For the medical records of this professional group, if the diagnosis is clear and this visit is a follow-up visit, it can be written in the position of chief complaint;
? Is the medical history the same as before? .
(3) Current medical history: focus on recording the effect and changes of the disease after treatment.
(4) Physical examination: record the necessary physical examination according to the change of illness.
(5) Auxiliary examination: Transcribe the positive and important negative examination results in the record.
(6) Diagnosis: If there is no change, it can be briefly described; If there is any change or change of doctor, you should write a diagnosis immediately.
(7), handling opinions:
1, for invasive examination, outpatient surgery patients must have:
(1), informed consent form and signature of patients and their families;
(2), preoperative routine examination is completed;
(3), there should be an invasive examination operation record or operation record.
Li Yu asked for the first medical record.
(8) Doctor's signature: the doctor is required to sign the recognizable full name.
The writing methods of outpatient (emergency) medical records mainly include the patient's name, gender, age, work unit or address, drug allergy history, medical record, laboratory examination (inspection report), medical image data, etc.
1. Fill in the patient's name, gender, date of birth, nationality, occupation, address, work unit, drug allergy history, etc. Every time you see a doctor, you should specify the department, year, month and day, and the records should be concise and focused.
2. Record the patient's brief medical history and signs (positive signs and necessary negative signs), examination items, examination results, preliminary diagnosis, drug name, dosage and usage, and treatment suggestions, such as hospitalization, surgery, consultation, changing majors, observation, and going home for rest and treatment. If a follow-up visit is needed, the time, contents and matters that the therapist should pay attention to should be clearly stated.
3. Follow-up medical records focus on the change of illness and the effect of diagnosis and treatment. Including the time, department, chief complaint, past history, necessary physical examination and auxiliary examination results, diagnosis and treatment opinions and doctor's signature. The initial diagnosis should be made on the day of the visit or during 1 visit and one or two follow-up visits. For those who are difficult to diagnose at the moment, you can temporarily state a symptom, such as? Does the fever need to be diagnosed (checked)? Wait a minute.
4. When urgent, serious and dangerous patients see a doctor, the time of seeing a doctor must be recorded to minutes. In addition to brief medical history and important signs, blood pressure, pulse, respiration, body temperature, state of consciousness, diagnosis and rescue measures should also be recorded. For those who died after outpatient rescue, the rescue process, time of death and diagnosis of death should be recorded, and the rescue record should be completed within 6 hours after death.
5. After the outpatient medical records are completed, the attending physician should sign the full name or affix the specified seal, and all outpatient medical records must be completed at the time of treatment.
6. The attending doctor of the first-visit department must write outpatient (emergency) medical records. If you need to ask other relevant departments for consultation or referral, the attending physician of the first-visit department should write clearly on the outpatient (emergency) medical record and issue an application form for referral or consultation. If the patient is inconvenient to move or is in critical condition, the first-visit department should be responsible for inviting doctors from relevant departments to come for consultation or examination, and should also write a record of consultation and examination results on the outpatient medical record, put forward diagnosis and treatment opinions, which will be implemented by the first-visit department to properly handle the patient.
7. The outpatient (emergency) medical records written by interns can take effect only after being reviewed and signed by the teaching teacher.
Model outpatient medical record Name: xxx Gender: Male Age: 45 years old Nationality: Han nationality Occupation: Cadre Address:No. xx, xx Lane, xx City Subject: General Internal Medicine
First diagnosis record
Xxxx year xx month XX8
Repeated upper abdominal pain for 3 years, aggravated for 3 months.
Since July 1996, I often feel dull pain in my upper abdomen before meals, which is mostly caused by improper diet. Accompanied by acid swallowing, irritability and anorexia, it can be relieved after meals. No history of fever, jaundice, hematemesis and melena. In the past three months, the attacks were frequent, the pain was irregular, the number of pain increased and aggravated, and there was no relief after eating.
In the past, he was healthy and had no history of liver disease or stomach disease.
Physical examination: p 75 times/min, blood pressure120/80mmhg (1610.7kpa), no yellow staining on the sclera, no palpable supraclavicular lymph nodes, mild tenderness in the middle of the upper abdomen, positive Murphy sign, no palpable mass, and normal bowel sounds. Preliminary diagnosis of abdominal pain to be investigated.
1. Examination of fecal occult blood 1. Diffuse gastritis
2. Gastroscopy of gastric and duodenal ulcer
3. B-ultrasound examination of gallbladder 2. Chronic cholecystitis 4. Ranitidine 0. l5BidX7d
Doctor's signature: xxx
Follow up record
Xxx year, xx month, xx day
The medical history is the same as before. After taking the medicine, the symptoms are relieved, the appetite is slightly increased, the acid reflux inhalation is reduced, and the energy is better than before. Physical examination: the sclera is not yellow, the abdomen is soft and flat, and the upper abdomen is tender.
Fecal occult blood was negative, gastroscopy showed chronic superficial gastric antrum inflammation, and gallbladder B-ultrasound was in the normal range. Diagnostic gastritis
Handling:
1. ranitidine 0. lSBidx 14d 2。 Metoclopramide lOmgTidX 14d.
3. The secret potassium of Broussonetia papyrifera
Doctor's signature: xxx