同济医学院诊断学课件.ppt

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同济医学院诊断学课件

The content of records are generally including Information from patient’s relatives (their hope, desire, and reflection; the information that the doctor induced to the patient’s relatives Monthly brief phase summary Time of record and signature The first record of the course of disease The first record of the course of the disease should be recorded at the same day as admission, its content and format are different from that of other record of course of the disease, including ① patient’s name, sex, age, chief complain, prominent signs and symptoms, results of those adjuvant examination, that are highly summarize and emphasizing the key profiles. ② Propose the preliminary diagnosis, differential diagnosis and their evidences, based upon above data. The first record of the course of disease ③ Propose some other special examinations in order to further confirm the diagnosis ④ Propose the treatment and diagnostic planning according to the actual situation of patients’ illness on admission Record of consultation If the patient presents other system disease, or symptoms difficult to diagnose, other specialist may be invited for consultation. In general, the consultant opinion will be written in consultant sheet. The consultant opinion includes brief description of case record, specialized examinations, the analysis and diagnosis of the disease, propose his opinion for further more precise examinations. Record of consultation If the opinions are collectively, record all those doctors participating the consultation, their analysis, examination, and treatment. Record for transferring to new department During the periods of hospitalization, the patient may present symptoms of other systems (department). With the approval of doctor of other department, the patient can now be transferred to the new department. It can be written in the record of the course of

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