肺炎 新生儿书写（Pneumonia, neonatal writing）.docVIP

肺炎 新生儿书写（Pneumonia, neonatal writing） In five days (i.e. one day time) was born in a hospital of Obstetrics and Gynecology, first full-term pregnancy, birth weight, 3 kg, new delivery, fetal distress and postpartum asphyxia, premature rupture of amniotic membrane and no meconium contamination, within 24 hours after birth without dyspnea, lactation normal. After 3 days of discharge, the cold and had close contact with the patient, the nasal congestion, breathing slightly promote lactation, choking 4, bursts of crying, restless sleep, self serving Bilin * * ml, three times a day at about 7, 00 invalid, breathing difficulties pale, mouth, nose incitement Zhou Qingzi, milk refusal, dont cry, listlessness, and gradually increased, eager to come to our hospital, outpatient hospital income to neonatal pneumonia. No fever, no cough, no vomiting, no convulsions, no cerebral palsy, and two normal symptoms. Cases are recorded, caused by the occurrence and development of diseases and treatment outcome of the medical records, doctors after asking history, detailed physical examination, an important data analysis and research, summed up and summarized, written after the obtained data, accurate and complete records not only the important basis for clinical diagnosis and treatment, and is the scientific research and teaching, and provides the main basis for political and legal work material. In the course of clinical work and teaching, the author often suffers from incomplete records, poor contents and insufficient reliability. In order to improve the writing quality of neonatal medical records, the following items should be paid attention to. 1 records of general projects Neonatal medical records are different from those in general pediatrics and adult medical records, In the conditions of the hospital medical records by neonatal table records, and at the grass-roots hospitals use more general pediatric medical records, therefore, often appear the following questions: (1) does not