培训课件--howtowritearecord.ppt

Data processing数据处理 Data processing is the clustering of data (数据分组) obtained from the history, physical examination, and laboratory and imaging studies. To fit as many of these clues together into a meaningful pathophysiologic relationship. Hypothesis(假设) Impression(印象) Primary diagnosis(初步诊断) Data processing数据处理 For example, suppose the interviewer obtains a history of dyspnea (呼吸困难), cough (咳嗽), earache (耳痛), and hemoptysis (咯血). Dyspnea, cough, and hemoptysis can be grouped together as symptoms suggestive of cardiopulmonary disease. Earache does not fit with the other three symptoms and may indicate another problem. Problem list development Problem list development results in a summary of the physical, mental, social, and personal conditions affecting the patient’s health. The problem list may contain an actual diagnosis or only a symptom or sign that cannot be clustered with other bits of data. The data on which each problem developed is noted. This list reflects the clinician’s level of understanding of the patient’s problem, which should be listed in order of importance. Problem list development The presence of a symptom or sign related to a specific problem is a pertinent positive. For example, a history of gout and increased uric acid level are pertinent positives in a man suffering from excruciating back pain radiating to his testicle. This patient may be suffering from renal colic secondary to a uric acid kidney stone. Problem list development The absence of a symptom or sign that, if present, would be suggestive of a diagnosis is a pertinent negative. A pertinent negative may be just as important as a pertinent positive; the fact that a key finding is not present may help rule out a certain diagnosis. For example, the absence of tachycardia in a women with weight loss and a tremor(震颤) makes a diagnosis of hyperthyroidism less than likely; the presence