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1、病历书写基本规范第一章基本要求第一条 病历是指医务人员在医疗活动过程中形成的文字、符号、图表、影像、切片等资料的总和，包括门(急)诊病历和住院病历。第二条病历书写是指医务人员通过问诊、查体、辅助检查、诊断、治疗、护理等医疗活动获得有关资料，并进行归纳、分析、整理形成医疗活动记录的行为。第三条病历书写应当客观、真实、准确、及时、完整、规范。第四条病历书写应当使用蓝黑墨水、碳素墨水，需复写的病历资料可以使用蓝或黑色油水的圆珠笔。计算机打印的病历应当符合病历保存的要求。第五条病历书写应当使用中文，通用的外文缩写和无正式中文译名的症状、体征、疾病名称等可以使用外文。第六条
2、病历书写应规范使用医学术语，文字工整，字迹清晰，表述准确，语句通顺，标点正确。washstomach,anusexhaust,theabdominalcavitypunctureindicationandoperationandtriplecavitiestubetheindicationsforuse,contraindicationsandconventionalmethodsofoperation.3.thehigherrequirements(1)learningcontent:abdominaltuberculosis(tuberculosisandTu
3、berculousperitonitis)andchronicdiarrhea.(2)clinicalknowledge,skillsrequired:①clinicalknowledge:thedifferentialdiagnosisoftuberculousperitonitis;thedifferentialdiagnosisofintestinaltuberculosisandCrohn'sdisease;thepathophysiologyofchronicdiarrheaanddiseases;IIskillsrequired:gastroscopy
4、andgastricjuiceextraction,theindicationofliverbiopsy,contraindicationsandcomplications,indicationofx-rayexaminationofthedigestivesystem.(11)endocrineProfessional1.familiarRotarypurpose:basictheoryofEndocrinologysubjectofinternalmedicine,hasasystemofacademicknowledge.Cultivationofclini
5、calthinkingability,masteringthedisciplineofclinicalskills,beabletohandlethesubjectofcommondiseases.Understanding:principlesofdiagnosisandtreatmentofcertaindiseases.2.basicrequirements(1)learningcontent:diabetesmellitusanditschroniccomplications,DiabeticKetoacidosis,Gravesdisease,thyro
6、iditis,andCushing'ssyndrome,aswellas,theoriginalprimaryhyperaldosteronismpheochromocytomatumor.(2)clinicalknowledge,skillsrequired:①clinicalknowledge:diabetestype,etiology,clinicalfeatures,treatment,dietprinciples;thepathogenesisofDiabeticKetoacidosis,theprinciplesofdiagnosisandtreatm
7、ent.Gravesdiseaseetiology,clinicalandlaboratoryandtreatment;IIskillsrequired:correcthistory,writtenrecords,conductacomprehensivephysicalexamination,familiarwiththediagnosisandtreatmentofendocrine17第七条病历书写过程中出现错字时，应当用双线划在错字上，保留原记录清楚、可辨，并注明修改时间，修改人签名。不得采用刮、粘、涂等方法掩盖或去除原来的字迹。上级医务人员有审查修改下级
8、医务人员书
