病院门诊病历质量考评标准(国外英文资料).docVIP

医院门诊病历质量考评标准 The evaluation criteria for the quality of the medical records in the hospital The mass is going to be Should the score Scoring criteria Real score Homepage project: fill in complete. Include: the patient name, sex, date of birth (childrens writing, month, day), career, nationality, address, work unit, marital status, history of drug allergy. Visit time (annual, monthly, daily emergency medical records should be specific to minute) 11 One is not eligible for one Main complaint: describe the main symptom, site nature and duration 8 Unrecorded eight points, and unstandardized three points Hpi: exact record of the process and the change of the disease (onset time, main symptoms, concomitant symptoms, diagnosis and treatment through, etc.), at the same time with several kinds of disease, should be focused on the main disease treatment, after more than can be briefly in 15 Missing 15 points and missing a 2 Previous history: a brief account of past history, personal history, family history and allergies (if not, should be noted) 10 The missing item is 10 points and the missing item is 2.5 Physical examination: key record of positive signs and important negative signs related to the disease 12 Unrecorded 12 points, incomplete buckle 2 Auxiliary inspection: list auxiliary inspection orders as required; Those who have been assisting the inspectors shall write the examination results. Please indicate the purpose and requirements of the consultation 9 To make a deduction of two points; The supplementary examination of unnecessary work shall be checked for two points; Missing a report is one point Diagnosis: definite diagnosis according to the specification written diagnosis (diagnosis should be exact, complete and write part, after writing the cause cannot replace diagnosis with symptoms) or write a preliminary diagnosis; If the diagnosis is difficult to be sure, after the name of the patient ? With the words 12 Ten points without a diagnosis; Non-standard 2 poin