同济医学院诊断学课件3.ppt

The writing of clinical record;The writing of clinical record;The basic requirement of clinical records;Special precautions;Types , formats and contents of clinical records;Clinical records during hospitalization; Chief compliant History of present illness Past illness Systemic review Personal history Marriage Reproductive and Gynecologic history Family history ;Physical examination;Physical examination;Physical examination;Physical examination;Physical examination;Physical examination;Physical examination;Physical examination;Abdomen ;Abdomen ;Abdomen ;Genitalia ;Physical examination ; Specialized subject: such as surgery, ophthalmology, gynecology etc. ;Laboratory and other special examinations ;Summary ;Common medical documents ;Record of admission ;The format and content of record of admission;Record of the course of disease ;The content of records are generally including ;The content of records are generally including ;The content of records are generally including ;The first record of the course of disease ;The first record of the course of disease ;Record of consultation ;Record of consultation ;Record for transferring to new department ;Record for transferring to new department ;Record of discharge ;Record of discharge ;Record of death ;Others ;Others ;Others ;Case record of readmission ;Case record of readmission ;Table format of case record ;Case record of out-patient ;Case record of out-patient--- requirement ;Case record of out-patient---content ;Case record of out-patient---content ;Further consultation ;Diagnostic reasoning in physical diagnosis;Diagnostic reasoning in physical diagnosis;Data collection;Data processing;Data processing;Data processing;Problem list development;Problem list development;Problem list development;Diagnostic reasoning;Diagnostic reasoning;Others ;Decision analysis ;Decision analysis ;The ways of clinical thinking ;The steps of clinical thinking;The steps of clinical thin