- 1、本文档共74页,可阅读全部内容。
- 2、原创力文档(book118)网站文档一经付费(服务费),不意味着购买了该文档的版权,仅供个人/单位学习、研究之用,不得用于商业用途,未经授权,严禁复制、发行、汇编、翻译或者网络传播等,侵权必究。
- 3、本站所有内容均由合作方或网友上传,本站不对文档的完整性、权威性及其观点立场正确性做任何保证或承诺!文档内容仅供研究参考,付费前请自行鉴别。如您付费,意味着您自己接受本站规则且自行承担风险,本站不退款、不进行额外附加服务;查看《如何避免下载的几个坑》。如果您已付费下载过本站文档,您可以点击 这里二次下载。
- 4、如文档侵犯商业秘密、侵犯著作权、侵犯人身权等,请点击“版权申诉”(推荐),也可以打举报电话:400-050-0827(电话支持时间:9:00-18:30)。
查看更多
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
您可能关注的文档
- 医学课件意外伤害的预防与生活技能的培养.ppt
- 医疗废物处置要求PPT课件.ppt
- 医学课件惡性肋膜積水.ppt
- 医疗废物管理办法PPT课件.ppt
- 医疗废物分类收集及处理.ppt
- 医学统计学(Introduction10912).ppt
- 医疗照射(诊断和治疗)防护.ppt
- 医学课件慢性乙型病毒性肝炎治疗中的常见问题及解答_1.ppt
- 医学课件慢性乙肝实验室检测及临床意义.ppt
- 医学课件意识障碍.ppt
- 德国租车用户分析报告:Miles & More-外文版培训课件2024.7.pdf
- 拉丁美洲付款方式分析报告-外文版培训课件2024.7,temu.pdf
- 有色金属行业市场前景及投资研究报告:黄金价格创新高,锡价走强.pdf
- 捷克电子商务行业市场前景及投资研究报告-外文版培训课件2024.7,temu,tiktok.pdf
- 哥伦比亚主要经济指标分析报告-外文版培训课件2024.7,temu.pdf
- 德国温室气体排放情况分析报告-外文版培训课件2024.7,风电,光伏,储能.pdf
- 德国联邦预算情况分析报告-外文版培训课件2024.7,temu.pdf
- 毕业论文-玩具手机外壳模具设计.doc
- 芬兰服装行业市场前景及投资研究报告-外文版培训课件2024.7,temu,tiktok.pdf
- 拉丁美洲金融科技行业市场前景及投资研究报告-外文版培训课件2024.7,temu,tiktok.pdf
文档评论(0)