病历书写(英文)
43页1、HISTORY RECORD,What is history record,The clinical record documents the patients history and physical findings. It shows how clinicians assess the patient, what plans they make on the patients behave, what actions they take, and how the patient responds to their efforts .,Importance of history record,1. Diagnosis and treatment purpose An accurate, clear, well organized record reflects and facilitates sound clinical thinking. It leads to good communication among the many professionals who partici
2、pate in caring for the patient 2. Teaching and research purpose 3. Medicolegal purposes,How to make a good history record,When creating a record, you do more than simply make a list of what the patient has told you and what you have found on examination. You must review your data, organize them, evaluate the importance and relevance of each item, and construct a clear, concise, yet comprehensive report.,How to make a good history record,1. Order is imperative 2. Keep items of history in the hist
3、ory 3. Describe specifically any pertinent negative information 4. Data not recorded are data lost 5. Use short words instead of long and probably fancier ones when they mean the same thing 6. Be objective 7. You should write the record as soon as possible,Basic requirement for the history record,1. To be well organized and canonical 2. No much erasion and gride could be done in the history record 3. To be objective and accurate 4. Using professional term to record instead of folksay 5. Remember
4、 to have your signature,A. Outline of case record,1. Biographical data Biographical information of patient should include his full name, age (date of birth), sex, race, occupation, nationality, marital status and permanent home address. Also, the date of admission, the time at which you took the history, the source of history and estimate of reliability should be involved. 2. chief complaint The chief complaint consists of main symptom(s) and duration. It should constitute in a few simple words
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