妇科护理病历的书写的.ppt

第一章 妇科护理病历 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. 病历（casehistory）是医务人员对患者疾病的发生、发展、转归，进行检查、诊断、治疗等医疗活动过程的记录。也是对采集到的资料加以归纳、整理、综合分析，按规定的格式和要求书写的患者医疗健康档案。 病历既是临床实践工作的总结，又是探索疾病规律及处理医疗纠纷的法律依据，对医疗、预防、教学、科研、医院管理等都有重要的作用。 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. 妇科护理病历书写 1病史采集 2体格检查 3护理评估 4护理计划 一般资料 病史资料 健康资料 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. 第一节病史采集 妇科护理病历 其方法包括：询问、听取、阅读、观察 和检查 病史采集是妇科健康评估的前提，对确定护理诊断、制定护理计划有重要意义 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. 病史内容 1、一般项目 2、主诉 3、现病史 4、月经史 5、婚姻史 6、既往史 7、个人史 8、家族史 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. 1一般项目 患者姓名、性别、年龄、籍贯、职业 民族、文化程度、家庭住址、身份证号码 电话号码、病史陈述者、可靠程度、入院日期、记录日期 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. 月经周期的表示方法 生育史的表示方法 月经期 初潮年龄 —————— 绝经年龄 月经周期 足月产、早产、流产及现存子女数 足-早-流-存 1-0-1-1 孕2产1 G2P1 妇科护理