内科病历修改注意事项.ppt

90/06/172:30pm ProgressNote-1S:painwhendefecationO:VitalsignsBP120/50,PR70,RR18,BT36.9 Consciousnessclear,neckJVE-, Chestbil.clearBS HeartRHBnomurmur, Abdomensoft,RUQtenderness,ovoid Extremitiesnopittingedema, Digital:externalhemorrhoid,yellowish stool,norectalshelf, I/O2240/1460, stoolpassage+ProgressNote-2A:1.BTIwEcolisepticemia2.HCVDwCHFFc.II3.AnginaPectoris4.URI5.Malnutrition6.Hyperuricemia7.CBDIHDstone,S/PPTCD+Stent8.GallstoneS/PCholecystectomy9.MultiplefractureS/Pop10.LVHRVH11.ExternalhemorrhoidP:1.KeepKeflexpo2.AddFaktucreamtopicaluse3.DCKasulonasalspray /R***SOAPUNDERSINGLEPROBLEM(SOAP前後呼應)範例ProgressNote96-01-1010AMS:…………..O:…………..A:CHFP:……ProgressNote96-01-1511AMS:…………….O:……………A:CHFP:…..CHF----progressnote範例ProgressNote96-01-209AMS:…………….O:……………A:CHFP:…..意見？ PROBLEMORIENTEDMEDICALRECORD(POMR)LoyolaUniversityChicago/LoyolaUniversityMedicalEducationNetworkDailyProgressNote 常見的錯誤重複記載“A” AcommonerrorinwritingdailyprogressnotesconcernsrestatingtheproblemundertheAssessmentinthedailynote. Example:Iftheproblemiscongestiveheartfailure,theAssessmentforthatparticularproblemonanydaycannotbecongestiveheartfailure.Thisissimplyarestatementoftheproblem.However,thephysicianmustgiveastatusreport(example-better,worse,oretiologydetermined)undertheassessment.01.Assessment的寫法：02.不是Diagnosis而已，是評估！應如何寫？03.試想，“我們如何向有醫療背景的家屬說明病患的病情進展及診療狀況”。 ProgressNote96-01-2010AMS:…………..O:…………..A:CongestiveHeartFailure,FcIII,improved,cardioechofavoredischemiccardiomyopathy…with…P:……CHF----progressnote範例Diagnosis/ProblemlistJaundice,cause?RecurrentrectalbleedingSmoking(since1964)Unemployed(Nov.2001)Initialproblemlist(onadmission)01TypeAhepatitis,resolvedHem