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