病历书写(英文)(课堂PPT)

HISTORYRECORD1WhatishistoryrecordTheclinicalrecorddocumentsthepatient'shistoryandphysicalfindings.Itshowshowcliniciansassessthepatient,whatplanstheymakeonthepatient'sbehave,whatactionstheytake,andhowthepatientrespondstotheirefforts.2Importanceofhistoryrecord1.DiagnosisandtreatmentpurposeAnaccurate,clear,wellorganizedrecordreflectsandfacilitatessoundclinicalthinking.Itleadstogoodcommunicationamongthemanyprofessionalswhoparticipateincaringforthepatient2.Teachingandresearchpurpose3.Medicolegalpurposes3HowtomakeagoodhistoryrecordWhencreatingarecord,youdomorethansimplymakealistofwhatthepatienthastoldyouandwhatyouhavefoundonexamination.Youmustreviewyourdata,organizethem,evaluatetheimportanceandrelevanceofeachitem,andconstructaclear,concise,yetcomprehensivereport.4Howtomakeagoodhistoryrecord1.Orderisimperative2.Keepitemsofhistoryinthehistory3.Describespecificallyanypertinentnegativeinformation4.Datanotrecordedaredatalost5.Useshortwordsinsteadoflongandprobablyfancieroneswhentheymeanthesamething6.Beobjective7.Youshouldwritetherecordassoonaspossible5Basicrequirementforthehistoryrecord1.Tobewellorganizedandcanonical2.Nomucherasionandgridecouldbedoneinthehistoryrecord3.Tobeobjectiveandaccurate4.Usingprofessionaltermtorecordinsteadoffolksay5.Remembertohaveyoursignature6A.Outlineofcaserecord1.BiographicaldataBiographicalinformationofpatientshouldincludehisfullname,age(dateofbirth),sex,race,occupation,nationality,maritalstatusandpermanenthomeaddress.Also,thedateofadmission,thetimeatwhichyoutookthehistory,thesourceofhistoryandestimateofreliabilityshouldbeinvolved.2.chiefcomplaintThechiefcomplaintconsistsofmainsymptom(s)andduration.Itshouldconstituteinafewsimplewordsthemainreasonswhythepatientconsulteddoctorandshouldbestateasnearlyaspossibleinthepatient’sownwards.Ingeneral,thechiefcomplaintshouldincludeage,sex,complaint,anddurationofthecomplaint.Itshouldnoincludeddiagnostictermsordiseaseentities.Forexample:”This70-yearoldmanhashadshortbreathforaweek.”73.Historyofpresentillness(HPI)Thehistoryofpresentillnessshouldbeawell-organized,sequentiallydevelopedelaborationofhischiefcomplaint(s)onitsvariouscharacteristics:①dateofonset,②characterofcomplaint,③modeofonset,courseandduration,④location,⑤relationshiptoothersymptoms,bodilyfunctionandactivities,⑥exacerbationandremissions,and⑦effectoftreatment.4.Pasthistory(PH)Itshouldincludeareviewofallpastillnesses,surgicalprocedures,andinjuries,andallergyhistory(medicine,food),whichareparticularlyrelatedtothepresentillness.85.Reviewofsystem(ROS)Thepurposeofsystemreviewistwofold:athoroughevaluationandadoublecheckpreventomissionofsignificantdatarelativetothepresentillness.Thereviewisacomprehensiveaccountofallcomplaintsreferabletoeachbodysystemprogressinginalogicalmannerfromtheheadtowardthefeet,includingrespiratorysystem,cardiovascularsystem,digestivesystem,Urinarysystem,hemopoieticsystem,endocrinesystem,nervoussystemandskeletalsystem.6.Personalhistory(socialandoccupationalhistory)Itincludespersonalhabits(smoking,alcoholdrinking),businesslife,sexlife,occupation(exposuretocertainirritatingagents),conditionofwork.97.MaritalhistoryItincludesdataconcerningthehealthofmate,sexualadjustment,thenumberofchildrenandtheirPhysicalstatus,andthegeneralsocialadjustmentwithinthefamily.8.Menstrualhistory(forfemalepatients)Ageofonset,intervalbetweenperiods,duration,amountandcharacterofflow,concomitantsymptoms,dateoflastmenstruation,ageofmenopause.9.Childbearing(reproductive)historyAgeanddateofpregnancy(ies)andchildbirth(s).Dateofartificialornaturalabortions,stillbirths,operativedelivery,puerperalfever.Methodoffamilyplanning,thepossiblefactorsofinfertility(alsoformalepatients).1010.Familyhistory(FH)Thehealthstatusofthepatient’sfamily(mother,father,siblingsandchildren)andifdied,theageandcauseofdeathshouldberecorded,suchasdiabetes,hypertension,cancer,obesity,allergicdisorders,coronaryarterydiseaseandmentalillness.11.Physicalexamination(PE)TherecordingofPhysicalexaminationshouldfollowalogicalsequenceasfollows:vitalsigns,generalstatus,skin,nodes,head,neck,chest,lungs,heartandbloodvessels,abdomen,genitalia,rectum,spineandextremities,nervousreflexes.12.LaboratorytestsandinstrumentalexaminationThefindingsofthemonklyservetoconfirmwhatyouhavefoundonhistoryandPhysicalexamination.Theroutinelaboratorystudiesincludeblood,urineandstooltests,electrolytes,X-raysandECG.1113Summary14.PrimarydiagnosisAstheresultsofdifferentialanalysisofanumberofsignificantdata,aprimarydiagnosiscouldbeestablished.Itconsistsofetiologicdiagnosis,pathologicaldiagnosis,pathophysioloicaldiagnosis(stageorperiodandclassificationorsubtype),cardiacor/andpulmonaryfunctionandcomplication(s).15.signature12BOutlineofSummaryName,gender,ageandoccupationAdmissiondateAhiefcomplainsPresenthistory(70%-80%percentoftheoriginalpresenthistory)Simplifieddocumentoftheoriginalpasthistory(onlypositivedatarecruited)VerysimplifieddocumentoftheoriginalpersonalandfamilyhistoryPhysicalexamination:vitalsigns,importantpositiveandnegativesigns,e