What experiences can you share about writing medical records?

First of all, medical records are not only legal documents, but also a true reflection of the condition, and the best carrier to reflect a doctor’s diagnosis and treatment level. At the same time, they are a physical object for peer communication and medical appraisal. Writing well requires repeated consideration, repeated practice, and continuous summary to improve. It can be said that there is only better, not the best. A good medical record, if the patient's condition has typical characteristics, can be diagnosed clearly when the patient comes in. Sometimes just the chief complaint can tell others what the patient's disease is and how long it lasted. For example, repeated coughing and wheezing for 15 years, worsening with shortness of breath for 2 days. This is the main complaint. The main complaint must be refined and cannot exceed 20 words including punctuation. This is a great test for a doctor’s induction and summary, as well as his understanding of the disease and the specific patient. Okay, you can see the level very well. Next is the history of current illness, which contains 7 contents. Even for patients whose onset time is less than 1 hour, the 7 elements of the history of current illness must be completely covered. This is a qualified history of current illness. Clinically unqualified ones abound. Especially surgical records. In fact, if you understand these 7 elements thoroughly, you can write it. A good history of current illness is based on asking the patient and reorganizing, summarizing, and sorting it through written thinking, and is truly reflected in time order. The biggest failure is that it cannot accurately reflect the patient's condition. This requires doctors to have a very solid foundation in diagnostics and syndrome differentiation! Because: For example, the patient may not understand what diarrhea is, and he tells you that he has diarrhea. Then the doctor needs to summarize the diagnosis by asking, does he really have diarrhea, or does he have more bloody stools? You need to further inquire about the frequency, water content, presence of mucus, presence of pus and blood, presence of undigested food, color, etc. . . Continue to ask if you have abdominal pain, nausea, or vomiting? How did it happen? Is there any cause? How did it develop and can it be relieved on its own? Have you been treated? Is it accompanied by fever? Are you dizzy? etc. Note that when asking patients, use language that can be understood by a variety of patients. When it comes to writing, it must be communication between peers, written language and format! ! It is really important to judge a symptom. Misjudgment will result in failure no matter how good the format of your writing is. I remember that I had just come to Guangdong from the north to work as a doctor. One day a patient called me when he was on duty and felt unwell. He said that his heart ached, OK. After a long time of questioning, including finally asking the patient to show me the pain with his fingers, I found that it was indeed pain under the xiphoid process. With further symptoms and electrocardiogram, it was clear that the patient had a stomach problem. After gastric medicine verification, it was confirmed that it was not a heart problem. The problem is, but: the patient tells you that it is pain in the chest, but it is written in the medical record that it is pain in the upper abdomen. There are many similar situations. The patient will only express his discomfort and will not tell you about the problem or disease. You have to find it yourself. This process is supported by the huge diagnostic knowledge behind it and the theoretical knowledge about the characteristics of various professions and diseases. There is no It is impossible to write a wonderful medical record with this support, because a doctor's thinking can be seen in the medical record! If you are a beginner, don’t be intimidated. Just follow the diagnostic requirements realistically and the record you get after asking will be a completely qualified medical record. Therefore, when it comes to writing medical records, there is only better, not the best. There is no limit to medical knowledge. . My miserable colleagues. Past history, personal history, menstruation, marriage and childbearing history, etc. are all very important, including a systematic disease review, which may provide clues to the final diagnosis for difficult patients. Therefore, true and accurate judgment and writing must be made. The same goes for physical examination. . Without a good basic physical examination skills, it is difficult to write a good medical record. Some also need to add diagnostic basis and differential diagnosis. You can see the level of a doctor here! Outpatient medical records: Write down the standard in a short period of time, each with its own method, because junior doctors cannot go out to outpatient clinics, so I won’t be verbose. Disease course records and various records: In fact, they all test the doctor's observation and thinking. If you write carefully, you can write well. When you are not familiar with the disease at the beginning, you might as well put professional books aside and compare the patient's condition and diagnosis and treatment process while writing. Disease outcome, prognosis, prevention and treatment to deepen your theoretical knowledge. Only by practicing theory, practicing theory, and practicing theory again can we write good medical records. Let’s talk about electronic medical records. Many people write medical records with the mentality of completing the task. Electronic medical records will completely destroy your capital as a doctor. Although the form can be copied, the thinking, individual diagnosis and treatment of patients, and observation must not be copied. No two patients are exactly the same. Only by putting your heart into it can you "write" good medical records. Accumulate your clinical experience and improve your level by writing medical records.

Go to sleep, *** encourage him. -------------------------------------------------- -------------------------------------------------- --------------------- Fonts really vary from person to person. There is a doctor in our department whose fonts are very difficult to read. It took me a long time to get used to it. His writing, however, is fine with most people. We also often criticize students with poor handwriting and punish them to practice writing large medical records, but still not everyone has beautiful handwriting. Also, the outpatient doctors are too busy, and they keep writing as fast as they can. In order for everyone to see that the handwriting of some doctors is still legible, I will post an outpatient medical record handwritten by three doctors that I saw recently to gain some comfort. . If this is still considered to be the case, then there is really no other way. The last writer is me, and my outpatient medical records are basically mediocre. :)) Therefore, it is very important for patients to carry outpatient medical records with them during follow-up visits. Doctors often base their medical records on medical records, and then make a decision based on the situation during the visit. Note: The outpatient medical records are in a format, but my follow-up consultation was not carried out according to the requirements. Because I have been seeing an old patient for many years, the medical records I wrote myself were more to facilitate my follow-up of patients in the future, so there are personal habits. This is allowed. You can also see that this is page 6 of the medical record, and this is already the patient's Nth outpatient medical record. If it is the first consultation, it must still be written according to the required format of the medical record, otherwise it will fail the examination! !