住出院病历摘要作业操作-马偕纪念医院.ppt

住/出院病歷摘要作業操作 ;住/出院病歷摘要作業操作 進入系統:;用滑鼠點選欲撰寫之患者點選 [ADMISSION NOTE] 鍵 (住院摘要) 或 [DISCHARGE SUMM] 鍵 (出院摘要) 或 [工具] 鍵建立快速鍵(片語);內科住院摘要(Admission Note)資料輸入:系統會依患者住院科別顯示該科住院摘要格式 ;;HISTORY[CHIEF COMPLAINT] 內容將轉至出院摘要之[主訴]欄位[PRESENT ILLNESS] 內容將轉至出院摘要之[病史]欄位;;Social History用滑鼠點選項目於選擇的資料上按滑鼠右鍵，可取消選取項目。Family History;Review of SystemsFor any positive symptoms not already described in the PI or PMH, explain in detail in the space at the right [e.g., duration, frequency, severity, especially if worsening, treatment sought, results of treatment, etc.].;;;;Physical ExaminationFor normal or negative findings, check the - box. For abnormal findings, check then + box and describe fully in the text box to the right. Further description of normal finding may be included there if needed. Do not mark any item you have not examined.;Problems Plan?逐行輸入，可使用上、下鍵或Enter鍵移動欄位。?於左邊的小箭頭?，Double Click 可刪除該行。;門診履歷 顯示該患者之門診履歷;出院摘要(Discharge Summary)資料輸入:[入/出院診斷] ?所有欄位均可用快速鍵輸入?入院診斷、主訴、病史欄位由住院摘要帶入;體檢發現 手術方法?體檢發現欄位由住院摘要帶入 ;住院治療經過 合併症 ;檢查記錄 本欄位由 [檢驗報告] 剪貼後可再修改放射線 病理 本欄位由 [檢驗報告] 剪貼後可再修改;出院指示] ?用滑鼠Double Click會帶出 “N.P.” ?內定狀態為 “改門診治療” ?用滑鼠Double Click會帶出“OPD followed-up”;檢驗報告?選擇檢驗項目(檢驗類、Ｘ光類、病理報告)?畫面顯示該患者住院期間之該類檢驗資料?點選欲查詢之項次後，畫面將會展開報告內容。?如欲摘錄本項檢驗資料，按[剪貼]鍵即可將內容貼至剪貼簿。;病摘列印 點選 [印表] / [病摘列印];點選;內科住院病人病歷書寫; 住/出院病歷摘要作業操作Admission Note and Discharge Summary;史記扁鵲倉公列傳;病歷記錄的功能;Components of Medical Record;書寫病歷的注意事項(1);書寫病歷的注意事項(2);書寫病歷的注意事項(3);Admission Note;Chief Complaint 主訴;Present illness (1) ;Present illness (2);Present Illness;Past History;Present Illness? Past History?;Occupational History;Family History;System Review;Physical Examination 身體檢查;Laboratory Findings;Problems list and management;Initial Plan;Problem List;Problem List;Progress Note --- SOAP;Progress Note;Discharge Summary