how to write a record PPT课件.ppt


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how to write a record_PPT课件The writing of clinical record
Department of Cardiology
Hainan Medical College
Yao Zhen
A patient’s health record plays many important roles and provides a view of the patient’s health history/status
The basic requirement of clinical records
In writing up the history and the physical examination, the examiner should obey the following rules:
Record all pertinent (相关的) data, avoid extraneous (无关的)data
Use standard format
prehensively, mon terms, avoid
nonstandard abbreviations(缩写)
The basic requirement of clinical records
Written in an all-round way, all items should be filled,
the hand writing should be clear, not scratchy(潦草)
or be altered
Be objective(客观), use diagram(图表) when
indicated
Types , formats and contents of clinical records
Clinical records during hospitalization
The clinical records should be written during hospitalization
It includes:
Case record /admission note
First record of admission
Record of the course of disease
Record of consultation
Record for transferring to new department
Record of discharge
Record of death
Record of surgery
Formats and contents of case record
identification
 
Name Sex(gender)
Age Marital status
Nationality (Race) Profession (occupation)Native place Current address
Data of admission Data of case record
Source (complainer) Reliability
plaint
History of present illness
Past illness
Systemic review
Personal history
Marriage
Reproductive and Gynecologic history
Family history
plain
一般由症状和持续时间两部分构成,不出现人物称谓和a,the等冠词。
主要有以下几种写法
+for+时间[Chest pain for 2 hours] 胸痛2小时
+of+时间如: [Nausea and vomiting of three days` duration] 恶心呕吐3天
+时间+in duration如: [Headache 1 month in duration] 头痛1月
+of+症状如: [Two-day history of fever] 发热2天

英文病历较少有我们的主诉里常常还要提到的症状性质——"阵发性"、"持续性"还是"反复"等等,是不是又一个英文和中文病历的不同不得而知,一般把"阵发性"译作intermittent,"持续性"译作persistent,而"反复发作的"就是recurrent,如果是"周期性的"则是periodic.

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  • 时间2017-11-24