病历书写规范（Medical record writing standard）.docVIP

病历书写规范（Medical record writing standard） I. hospital records (I) complaining The main symptoms, signs, and duration of a patients visit. Special cases have exceptions: Admission record 1, the confirmed chronic disease follow-up case, asymptomatic symptoms, the main complaint can be written: x x x x months, for re visit, re admission. This condition is not diagnostic instead of chief complaint. For example, diagnosed leukemia for 3 months, for re chemotherapy admission. Or 1 years after the internal fixation of the right forearm fracture for further consultation. Admission record 2, the treatment process is complex, repeated hospitalized patients, the current medical history should start from the onset of the narrative, the main complaint is based on treatment or diagnosis of a brief description. As a cancer patient, first chemotherapy after resection of the lesion, and radiotherapy after admission, complaints can be resected stage for treatment, writing 2 months * * tumor resection after 1 months at the time of admission to follow-up after radiotherapy. In this case, the complaint is consistent with the current medical history. Admission record 3, special department medical records, such as plastic surgery, in the case of no symptoms and signs, can write the patients conscious abnormal signs. Such as consciously mandibular angle width, affecting the appearance of 15 years.. However, the symptoms, signs and duration of symptoms after burn or post-traumatic deformities and dysfunction should be noted. Admission record (two) present medical history; Refers to the patients occurrence, evolution, diagnosis and treatment of the whole process, should be written in chronological order, the main contents include: the cause of the disease; The incidence of symptoms, the main characteristics and development changes, accompanied by symptoms; after the onset of treatment and outcome; changes in sleep and diet in general and related to the diagnosis of positive or negative informa