(a) the first course record refers to the first course record written by the attending physician or the doctor on duty after the patient is admitted to the hospital, which should be completed within 8 hours after the patient is admitted to the hospital. The contents of the first diagnosis record include the characteristics of the case, the discussion of the proposed diagnosis (diagnosis basis and differential diagnosis), the diagnosis and treatment plan, etc.
1. Case characteristics: The characteristics of this case should be written after comprehensive analysis, induction, collation of medical history, physical examination and auxiliary examination, including positive findings and negative symptoms and signs with differential diagnosis significance.
2. Quasi-diagnosis discussion (diagnosis basis and differential diagnosis): according to the characteristics of the case, put forward the preliminary diagnosis and diagnosis basis; Write differential diagnosis and analyze unknown diagnosis; And analyze the next diagnosis and treatment measures.
3, diagnosis and treatment plan: put forward specific examination and treatment measures.
Medical record is a record of the occurrence, development, outcome, examination, diagnosis and treatment of patients' diseases. It is also a patient's medical and health record written in accordance with the prescribed format and requirements by summarizing, sorting and comprehensively analyzing the collected data.
Medical records are not only the summary of clinical practice, but also the legal basis for exploring the laws of diseases and handling medical disputes, and are the precious wealth of the country. Medical record plays an important role in medical treatment, prevention, teaching, scientific research and hospital management.
Extended data:
Requirements for writing outpatient medical records
1, the cover content of outpatient medical records should be carefully filled in item by item. Fill in the patient's name, gender, age, work unit or address, outpatient number and public (self) fee from the registration room. X-ray number, electrocardiogram and other special inspection numbers, drug allergy, hospitalization number, etc. It should be filled out by a doctor.
2. The medical records of newly diagnosed patients should include "five signatures" (chief complaint, medical history, physical examination, preliminary diagnosis, treatment opinions and doctor's signature).
(1) Medical history should include present medical history, past medical history, personal history related to diseases, marriage, menstruation, birth history, family history, etc. ;
② Physical examination should record the main positive bodies and negative signs with differential diagnosis significance.
(3) List the names of diseases that are initially diagnosed or most likely, and try to avoid using words such as "to be investigated" and "to be diagnosed".
(4) The treatment opinions should list the drugs used and special treatment methods, further examination items, matters needing attention in life, rest methods and time limit; If necessary, record the appointment date and follow-up requirements.
3. Follow-up patients should focus on the diagnosis and treatment results and the evolution of the disease after the previous follow-up; Physical examination can focus on the last positive discovery and the newly discovered signs; Supplementary necessary auxiliary inspection and special inspection. For patients who cannot be diagnosed for three times, the attending doctor should ask the superior doctor for consultation. For diseases different from last time, all outpatient medical records should be written according to newly diagnosed patients.
Baidu Encyclopedia-Basic Specification for Medical Record Writing
Baidu Encyclopedia-Medical Records