病历书写各种记录（Medical records are written in various records）.doc

病历书写各种记录（Medical records are written in various records） The fourth chapter describes the writing requirements of various records Duration record The course record is a record of the patients condition, evolution, diagnosis and treatment, and other special conditions during hospitalization. (a) the completion time of the course record; 1. first course of disease Emergency critical patients were completed in time and patients were completed within 24 hours. 2. general course record Keep records of critically ill patients, patients were recorded daily, and indicate the specific recording time (when a bit); general patients every 1 to 3 days to record a; chronic disease, recovery period and stable disease 5 day record at a time; after surgery should be recorded for 3 consecutive days, after treating patients according to the records request. (two) record of the course of disease 1. first course of disease For the first time course record includes: name, gender, age, occupation and other general projects. The main clinical symptoms and signs, laboratory examination and inspection equipment, preliminary diagnosis and diagnosis, treatment plan (including the preliminary examination, treatment and nursing measures etc.). Critically ill patients should be detailed records of the rescue, medication dosage, methods and execution time, as well as to the families or units of the situation, and to observe the changes in attention to matters. Doctors at higher levels should review and sign in time. 2. general course record (1) the change of the illness, the analysis of the possible causes and treatment opinions, the patients thoughts, diet, defecation and so on. (2) to timely and truthfully record the analysis, diagnosis and treatment advice, case discussion, and other diagnosis and treatment suggestions made by doctors at the higher level, which should reflect the three rounds ward rounds. (3) the implementation of the treatment plan, efficacy and response, laboratory and specia