病历书写与教学查房（Medical writing and teaching rounds）.docVIP

病历书写与教学查房（Medical writing and teaching rounds） Medical writing and teaching rounds China Medical University Second Hospital Institute of Gastroenterology Li Yan Medical records is the hospital clinic work and scientific records, is the basic data of clinical research, medical record writing should be neat, and to enrich the content accurately, on the need of patient treatment and clinical research needs. Medical records quality directly reflects the hospital medical level and management level. The medical record is a permanent record, with indelible ink block letters, no spaces or travel. The words should be concise, writing should be clear, disable the informal expressions and simplified characters or simply non universal English abbreviations. Each page of paper records are written the name and the number of hospitalized patients, each record in Arabia code written date, pathography not deleted, such as deletion must be signed and dated by the deletion of people. Permanent communications office pathography must be patient, to follow up. Basic Requirements True The terminology standard format Project fully legible Chief complaint: for patients and most obvious symptoms or signs, and explain the time. History: occurrence, development and evolution of disease patients. Include Cause / inducement and onset The main characteristics of symptoms: location, nature, duration and extent, alleviate or exacerbate factors The development of disease and evolution: the changes of main symptom / new symptoms After the previous treatment: With symptoms suggestive of degree, narrow scope, the exclusion of other The general situation in the course of Hospital medical records General project: auxiliary examination: Chief complaint: summary records: History: a preliminary diagnosis: Past history: the principle of treatment: Personal history: confirm the diagnosis: Family history: date of diagnosis: Physical examination: the doctor diagnosed: : Case Name: Wang gender: male age: 54 Nati