口腔外科学0101（Oral surgery 0101）.docVIP

口腔外科学0101（Oral surgery 0101） The basic knowledge and basic operation is an important basis for correct clinical practice and scientific basis, basic knowledge and basic operation is correct, skilled or not, is the key to ensure the quality and success of the treatment of disease. Section 1 history and examination of oral and maxillofacial surgery Medical record refers to all the medical data of the patient in the outpatient, emergency, detention and hospitalization. The medical record is the medical process of the illness and the physician truthfully, physicians for medical work is an important basis for medicine, teaching and research, prevention of medical information resources, is the official medical documents with legal effect. High quality medical record is a sign of training. It not only reflects the academic level and work attitude of doctors, but also represents the level of scientific management in departments and hospitals. Outpatient medical record Oral and maxillofacial surgery outpatient patients account for the vast majority, so it should be written out of out-patient medical records. Strive for complete content, concise, focused, clear text, easy identification, drug name spelling error, writing outpatient medical records should pay attention to the following points: (1) outpatient medical records project requirements; Name, sex, age, marriage, occupation, place of birth, nationality (nationality), residence / residence address, telephone number, work unit and telephone, name of allergy drug and date of medical treatment and diagnosis. 1. outpatient medical record covers must be filled out one by one. Every 2. patients must be complete and fill out the date of visit (emergency patients must fill, and medical departments), if the patient has visited more than two departments, while subjects were filled out the date and subject. Complete all 3. outpatient medical history should include the following contents: 1. The history of the complaint;; physical