病历书写的方向与重点.pptVIP

蘇育敏 為什麼要寫病歷？ 病人照護的指引 診療上溝通的工具 業務文書具法律效力 教學研究的重要材料 保險給付的重要依據 臨床和醫政決策的參考 病歷的結構 臨床記錄 病史 身體檢查 臨床觀察 醫囑 診斷和治療處置報告 會診報告 出院摘要 行政記錄 人口學和財務方面的資料 同意書 入院病歷(admission note) 主訴(chief complaint) 現病史(present illness) 過去病史(past history) 個人史(personal history) 家族史(family history) 器官系統複查(review of systems) 身體檢查(physical examination) 影像及實驗室檢查(image and lab examination) 暫定診斷(tentative diagnosis) 診療計畫(diagnostic and therapeutic plan) 病程記錄 病程記錄(progress note) 每週摘要(weekly summary) 交班記錄(on-service and off-service note, transfer note, acceptance note) 入院病歷(admission note)—主訴(chief complaint) 本次入院的主要症狀或原因 症狀 發作的緩急 症狀持續時間 不一定成句，以病人話語說 Acute onset abdominal pain for 2 days Intermittent epigastralgia for 1 months Right hand pain after traffic accident 2 hours before admission 入院病歷(admission note)現病史(present illness 本次症狀的前因後果 注意時序性 重要病史的描述 DM in wound infection Hypertension in CAD 入院病歷(admission note)現病史(present illness This 24 year-old male suffered from epigrastralgia 2 days ago. The pain was dull and intermittent. The pain became obvious 1 day later and shifted to right lower quadrant of abdomen. Poor appetite and fever developed at the same day. He visited our ER this morning. Physical examination and laboratory data supported diagnosis of acute appendicitis. He received laparoscopic appendectomy and was admitted to ward for further management. 入院病歷(admission note)過去病史(past history) 疾病史 長期服用的藥物 手術史 藥物過敏史 入院病歷(admission note)個人史(personal history) 個人嗜好習慣 抽煙 喝酒 檳榔 個人職業 旅遊史 女性的懷孕史 入院病歷(admission note)家族史(family history) 過敏 糖尿病 高血壓 遺傳疾病 樹狀圖—三代 入院病歷(admission note)器官系統複查(review of systems) 避免遺漏的工具 入院病歷(admission note)身體檢查(physical examination) 身高、體重、生命徵象 頭、頸、胸、腹、四肢、皮膚 神經系統 周邊脈搏 淋巴系統 入院病歷(admission note)影像及實驗室檢查(image and lab examination) 擷取和本次住院有關之檢查 入院病歷(admission note)暫定診斷(tentative diagnosis) 可能的診斷或臆斷 Rule out(排除) 的錯誤使用 Probable, to exclude, suspect Fever rule out UTI Fever suspect UTI Fever, probable UTI, to exclude drug fever 入院病歷(admission note)診療計畫(diagnostic and therapeutic pla