上海交通大学：《诊断学》课程PPT教学课件（英语版）Chapter 27 The writing of clinical record

The writing of clinical record A patients health record plays many important roles It provides a view of the patient's health history/status It serves as the legal document describing the healthcare services provided to the patient It provides a method for clinical communication and care planning among the individual healthcare practitioner serving the patient

The writing of clinical record A patient’s health record plays many important roles: • It provides a view of the patient’s health history/status • It serves as the legal document describing the healthcare services provided to the patient • It provides a method for clinical communication and care planning among the individual healthcare practitioner serving the patient

The writing of clinical record It documents and substantiates the patients clinical care and serves as a key source of data for outcomes research and public health purposes It provides as a major resource for healthcare practitioner education It serves to document evidence of the quality of patient care

The writing of clinical record • It documents and substantiates the patient’s clinical care and serves as a key source of data for outcomes research and public health purposes • It provides as a major resource for healthcare practitioner education • It serves to document evidence of the quality of patient care

The basic requirement of clinical records In writing up the history and the physical examination, the examiner should obey the following rules Record all pertinent data, avoid extraneous data · Use standard format Describe comprehensively, use common terms, avoid nonstandard abbreviations Written in an all-round way, all items should be filled the hand writing should be clear, not scratchy or be altered Be objective. use diagram when indicated

The basic requirement of clinical records In writing up the history and the physical examination, the examiner should obey the following rules: • Record all pertinent data, avoid extraneous data • Use standard format • Describe comprehensively, use common terms, avoid nonstandard abbreviations • Written in an all-round way, all items should be filled, the hand writing should be clear, not scratchy or be altered • Be objective, use diagram when indicated

Special precautions The patient' s medical records is a legal document Comments regarding the patients behavior and attitudes should not be part of the record unless they are important from a medical or scientific standpoint a statement such as" the examination of the eyes is normal is much less accurate than the fundus is normal In the first case. it is not clear whether the examiner actually attempted to look at the fundus

Special precautions • The patient’s medical records is a legal document • Comments regarding the patient’s behavior and attitudes should not be part of the record unless they are important from a medical or scientific standpoint • A statement such as “the examination of the eyes is normal” is much less accurate than “the fundus is normal” • In the first case, it is not clear whether the examiner actually attempted to look at the fundus

Types, formats and contents of clinical records

Types , formats and contents of clinical records

Clinical records during hospitalization The clinical records should be written during hospitalization It includes Case record First record of admission Record of the course of disease Record of consultation Record for transferring to new department Record of discharge Record of death Record of surgery

Clinical records during hospitalization • The clinical records should be written during hospitalization • It includes: Case record First record of admission Record of the course of disease Record of consultation Record for transferring to new department Record of discharge Record of death Record of surgery

Case record The case record should be written systemically and completely within 24 h by intern

Case record The case record should be written systemically and completely within 24 h by intern

Formats and contents of case record Case record Name Sex Age Marital status Nation Profession Native place Current address Data of admission Data of case record Source Reliability

Formats and contents of case record • Case record Name Sex Age Marital status Nation Profession Native place Current address Data of admission Data of case record Source Reliability

Chief compliant History of present illness Past illness Systemic review Personal history Marriage Reproductive and gynecologic history Family history

• Chief compliant • History of present illness • Past illness • Systemic review • Personal history • Marriage • Reproductive and Gynecologic history • Family history

Physical examination Temperature Pulse R espiratory Blood pressure General appearance development nutrition(well, moderate, poor) facial expression(acute or chronic, suffering expression, anxiety. fear, calm) position, gait and mental status(alert, obscure, lethargy, coma) cooperative

Physical examination Temperature Pulse Respiratory Blood Pressure • General appearance: development, nutrition (well, moderate, poor) facial expression (acute or chronic, suffering expression, anxiety, fear, calm) position, gait and mental status (alert, obscure, lethargy, coma); cooperative