病历书写英文.pptxVIP

病历书写英文病历书写英文第1页

WhatishistoryrecordTheclinicalrecorddocumentsthepatientshistoryandphysicalfindings.Itshowshowcliniciansassessthepatient,whatplanstheymakeonthepatientsbehave,whatactionstheytake,andhowthepatientrespondstotheirefforts.病历书写英文第2页

Importanceofhistoryrecord1.DiagnosisandtreatmentpurposeAnaccurate,clear,wellorganizedrecordreflectsandfacilitatessoundclinicalthinking.Itleadstogoodcommunicationamongthemanyprofessionalswhoparticipateincaringforthepatient2.Teachingandresearchpurpose3.Medicolegalpurposes病历书写英文第3页

HowtomakeagoodhistoryrecordWhencreatingarecord,youdomorethansimplymakealistofwhatthepatienthastoldyouandwhatyouhavefoundonexamination.Youmustreviewyourdata,organizethem,evaluatetheimportanceandrelevanceofeachitem,andconstructaclear,concise,yetcomprehensivereport.病历书写英文第4页

Howtomakeagoodhistoryrecord1.Orderisimperative2.Keepitemsofhistoryinthehistory3.Describespecificallyanypertinentnegativeinformation4.Datanotrecordedaredatalost5.Useshortwordsinsteadoflongandprobablyfancieroneswhentheymeanthesamething6.Beobjective7.Youshouldwritetherecordassoonaspossible病历书写英文第5页

Basicrequirementforthehistoryrecord1.Tobewellorganizedandcanonical2.Nomucherasionandgridecouldbedoneinthehistoryrecord3.Tobeobjectiveandaccurate4.Usingprofessionaltermtorecordinsteadoffolksay5.Remembertohaveyoursignature病历书写英文第6页

A.Outlineofcaserecord1.BiographicaldataBiographicalinformationofpatientshouldincludehisfullname,age(dateofbirth),sex,race,occupation,nationality,maritalstatusandpermanenthomeaddress.Also,thedateofadmission,thetimeatwhichyoutookthehistory,thesourceofhistoryandestimateofreliabilityshouldbeinvolved.2.chiefcomplaintThechief