How to open a medical record for asthma

Outpatient medical record

(1) The cover content of the outpatient medical record must be filled in carefully item by item. The patient's name, gender, age, work unit or address, clinic number, and public (private) expenses should be filled in by the registration office. X-ray film number, electrocardiogram and other special examination number, drug allergy status, hospitalization number, etc. must be filled in by the doctor.

(2) The medical records of newly diagnosed patients should contain the "five-one signatures" (chief complaint, medical history, physical examination, preliminary diagnosis, treatment opinions and physician's signature). Among them: ① Medical history should include current medical history, existing medical history, and personal history related to the disease, marriage, menstruation, childbirth history, family history, etc. ②The physical examination should record the main positive signs and negative signs with differential diagnosis significance. ③ List the names of the initially determined or most likely disease diagnoses in separate rows, and try to avoid using words such as "to be investigated" and "to be diagnosed". ④ The handling opinions should list the drugs and special treatment methods used, further examination items, daily life precautions, rest methods and duration; if necessary, record the date of outpatient appointment and follow-up requirements, etc.

(3) Return-examination patients should focus on recording the diagnosis and treatment results and disease evolution since the previous visit; the physical examination can be more focused, and the last positive findings should be re-examined, and new findings should be noted. Physical signs; supplement necessary auxiliary examinations and special examinations. For patients who cannot be diagnosed three times, the treating physician should ask a superior physician for examination. For diseases that are different from the last time, outpatient medical records will be written as newly diagnosed patients.

(4) The date of visit should be filled in for each visit, and emergency patients should fill in the specific time.

(5) When requesting consultation from other departments, the purpose, requirements and preliminary opinions of the undergraduate department should be clearly filled out in the medical record and signed by a senior physician of our hospital.

(6) The invited consulting physician (a senior physician in our hospital) should fill in the examination findings, diagnosis and treatment opinions in the consultation medical record.

(7) When outpatients require hospitalization for examination and treatment, the doctor shall fill in the hospitalization certificate.

(8) Outpatient physicians should be responsible for filling in medical record abstracts for referred patients.

(9) For notifiable infectious diseases, the epidemic reporting status should be indicated.

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