2014年业务考试题(国外英文资料).docVIP

2014年业务考试题 The 2014 business test (August) 1, fill in the blanks (0.50 points, a total of 26 points) 1, medical record writing should be basic principle (),,,,,,. 2, and written records, should be after the registration of medical institutions of medical personnel review, modify and signature. All medical records shall be written on the date and time of the written record. The diagnosis of traditional Chinese medicine, including sum, is involved in the writing of TCM medical records. Any medical activities that require the approval of the written consent of the patient shall be signed by the consent of the consent of the consent. If the patient does not have full capacity for civil conduct, it shall be signed by him. If a patient cannot sign for illness, it shall be signed by him. Due to the implementation of medical protective measures that is unfavorable to the patients, relevant information shall be informed patient close relatives, by signing informed consent, and record in time. The doctors order must not be altered. In case of cancellation, the label should be cancelled and signed. 7, please write the following record writing time limit: course record for the first time: hours, hospital records: hours, attending physician ward inspection records for the first time: hours, stage summary:, invasive diagnosis and operation records: records: the operation, postoperative course record for the first time: complete, save records, and save the doctors advice: after the rescue Hours according to solid n, and indicate. The chief complaint is the one that motivates the patient. Content including hpi, main symptom characteristics and development situation, after, after diagnosis and treatment and results, and etc. In general, as well as related to the differential diagnosis of, or, etc. Daily medical records writing requirement: the patient, according to the change of the disease at any time, daily to Less time, more detail; Patients with a serious illness, at least one o