《诊断理论》病历书写.ppt

* * 病历书写 顾其华 博士 中南大学湘雅医院呼吸科副教授 Medical Record The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patients medical history and care across time within one particular health care providers jurisdiction. Define The medical record includes a variety of types of notes entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accu