同济医学院诊断学课件3.ppt

The writing of clinical record A patient’s health record plays many important roles: It provides a view of the patient’s health history/status It serves as the legal document describing the healthcare services provided to the patient It provides a method for clinical communication and care planning among the individual healthcare practitioner serving the patient The writing of clinical record It documents and substantiates the patient’s clinical care and serves as a key source of data for outcomes research and public health purposes It provides as a major resource for healthcare practitioner education It serves to document evidence of the quality of patient care The basic requirement of clinical records In writing up the history and the physical examination, the examiner should obey the following rules: Record all pertinent data, avoid extraneous data Use standard format Describe comprehensively, use common terms, avoid nonstandard abbreviations Written in an all-round way, all items should be filled, the hand writing should be clear, not scratchy or be altered Be objective, use diagram when indicated Special precautions The patient’s medical records is a legal document Comments regarding the patient’s behavior and attitudes should not be part of the record unless they are important from a medical or scientific standpoint A statement such as “the examination of the eyes is normal” is much less accurate than “the fundus is normal” In the first case, it is not clear whether the examiner actually attempted to look at the fundus Types , formats and contents of clinical records Clinical records during hospitalization The clinical records should be written during hospitalization It includes: Case record First record of admission Record of the course of disease Record of consultation Record for transferring to new department Record of discharge Record of death Record of surgery Case record