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1、ThewritingofclinicalrecordApatient’shealthrecordplaysmanyimportantroles:Itprovidesaviewofthepatient’shealthhistory/statusItservesasthelegaldocumentdescribingthehealthcareservicesprovidedtothepatientItprovidesamethodforclinicalcommunicationandcareplanningamongtheindividualhealthca
2、repractitionerservingthepatientThewritingofclinicalrecordItdocumentsandsubstantiatesthepatient’sclinicalcareandservesasakeysourceofdataforoutcomesresearchandpublichealthpurposesItprovidesasamajorresourceforhealthcarepractitionereducationItservestodocumentevidenceofthequalityofpat
3、ientcareThebasicrequirementofclinicalrecordsInwritingupthehistoryandthephysicalexamination,theexaminershouldobeythefollowingrules:Recordallpertinentdata,avoidextraneousdataUsestandardformatDescribecomprehensively,usecommonterms,avoidnonstandardabbreviationsWritteninanall-roundway
4、,allitemsshouldbefilled,thehandwritingshouldbeclear,notscratchyorbealteredBeobjective,usediagramwhenindicatedSpecialprecautionsThepatient’smedicalrecordsisalegaldocumentCommentsregardingthepatient’sbehaviorandattitudesshouldnotbepartoftherecordunlesstheyareimportantfromamedicalor
5、scientificstandpointAstatementsuchas“theexaminationoftheeyesisnormal”ismuchlessaccuratethan“thefundusisnormal”Inthefirstcase,itisnotclearwhethertheexamineractuallyattemptedtolookatthefundusTypes,formatsandcontentsofclinicalrecordsClinicalrecordsduringhospitalizationTheclinicalrec
6、ordsshouldbewrittenduringhospitalizationItincludes:CaserecordFirstrecordofadmissionRecordofthecourseofdiseaseRecordofconsultationRecordfortransferringtonewdepartmentRecordofdischargeRecordofdeathRecordofsurgeryChiefcompliantHistoryofpresentillnessPastillnessSystemicreviewPersonal
7、historyMarriageReproductiveandGynecologichistoryFamilyhistoryPhysicalexaminationTemperaturePulseRespiratoryBloodPressureGeneralappearance:development,nutrition(well,moderate,poor)facialexpression(acuteorchronic,sufferingexpression,anxiety,fear,calm)position,gaitandmentalstatus(al
8、ert,obscure,lethargy,coma);cooperativePh
