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急性上呼吸道沾染临床门路表单(国外英文资料)
急性上呼吸道感染临床路径表单(国外英文资料)
Acute upper respiratory tract infection clinical pathway form
Subject: the first diagnosis was acute upper respiratory infection (icd-10: J15.901)
Patient name: age: outpatient number: hospital number:
Date of hospitalization: the day of the year: the day of the month: the day of the day: 5-7 days
time
1-3 days in hospital
hospitalization
The main
to
clinical
healing
work
As a
Ask for medical history and physical examination
The initial assessment of the disease
The doctor is checking the room
Evaluate the risk factors of a specific pathogen and conduct initial experience against infection
Open the certificate and complete the writing of the medical records
The doctor is checking the room
Check whether the result of the assisted inspection is abnormal
Assess the condition, maintain the original treatment or adjust the antimicrobial agent
Observe the adverse effects of the drug
A resident writes a course of illness
heavy
point
The medical
c.
Long-term orders:
Respiratory care routine
One to three levels of care (depending on the condition)
Oxygen (necessary)
Antibacterial drugs (cephalospores)
- expectorant
Temporary orders:
Blood routine, urine routine, stool routine
Kidney function, electrolyte, blood sugar,
The chest is positive and ecg
- blood sedimentation CRP infectious disease screening Etiology examination and drug susceptibility of blood gas analysis, lateral thoracic slice Chest CT blood culture ultrasound (if necessary)
cross-treatment
Long-term orders:
Respiratory care routine
One to three levels of care (depending on the condition)
Oxygen (necessary)
Antibacterial drugs (cephalospores)
- expectorant
Adjust antimicrobial drugs according to the disease
Temporary orders:
cross-treatment
Review blood routine
Chest CT (if necessary)
Abnormal indicators review
Medical examination (if necessary)
There is a invasive test (necessary)
Primary care
work
Introduce the environment, facilities and equipment of the ward
Hospitalization assessmen
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