howtowritearecord

The writing of clinical record,Department of CardiologyHainan Medical CollegeYao Zhen,A patients health record plays many important roles and provides a view of the patients health history/status,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 (相关的） data, avoid extraneous （无关的）data Use standard format Describe comprehensively, use common terms, avoid nonstandard abbreviations（缩写）,The basic requirement of clinical records,Written in an all-round way, all items should be filled, the hand writing should be clear, not scratchy（潦草） or be altered Be objective(客观）, use diagram（图表） when indicated,Types , formats and contents of clinical records,Clinical records during hospitalization,The clinical records should be written during hospitalization It includes: Case record /admission note First record of admissionRecord of the course of diseaseRecord of consultationRecord for transferring to new departmentRecord of dischargeRecord of deathRecord of surgery,Case record,The case record should be written systemically and completely within 24 h by intern,Formats and contents of case record,identification Name Sex(gender)Age Marital statusNationality (Race) Profession （occupation）Native place Current addressData of admission Data of case recordSource (complainer) Reliability,Chief complaint History of present illness Past illness Systemic review Personal history Marriage Reproductive and Gynecologic history Family history,Chief complain,一般由症状和持续时间两部分构成，不出现人物称谓和a，the等冠词。主要有以下几种写法l.症状+for+时间 Chest pain for 2 hours 胸痛2小时2.症状+of+时间如： Nausea and vomiting of three days duration 恶心呕吐3天3.症状+时间+in duration如： Headache 1 month in duration 头痛1月4.时间+of+症状 如： Two-day history of fever 发热2天 英文病历较少有我们的主诉里常常还要提到的症状性质 阵发性、持续性还是反复等等，是不是又一个英文和中文病历的不同不得而知，一般把阵发性译作intermittent，持续性译作persistent，而反复发作的就是recurrent，如果是周期性的则是periodic.,History of present illness,A：The immediate history that brought the patient to the hospitalB：Background history of disease leading to the immediate historyC：Significant positive and negative data that might give clues useful in differential diagnosis,History of present illness,是整个病历中最难的部分1.时态的问题。整个现病史的的应主要为过去时，以用于描述起病及就诊等时间点上的动作，例如The patient felt fatigue and nausea three days ago without any obvious inducing factors. So the patient came to our hospital and was accepted as chronic hepatitis B.而现病史最后的一般情况部分则用现在时较佳，以为是一直如此到现在的情况，如Since onset， her appetite is not good， and both her spiritedness and physical energy are bad. Defecation and urination are normal.如果要突出疾病一直持续至今则用现在完成时，如发现患糖尿病五年 译作He has suffered from DM for five years.较好，而译作He suffered from DM for five years.则让人有不知已愈未愈之感。而提到以前有但是现在未再出现的症状或疾病时，应该用过去完成时或加上说明的过去时，如He had suffered from abdominal pain for one week by March 8th. 及Two weeks prior to this admission， he had an episode of abdominal pain that lasted one week.,2.要保持主语和谓语的一致，整个现病史的主语应该是the patient，不应有He found lung cancer 1 year ago之类的句子出现。被动式也少用为妙，接受检查，治疗可以用receive，accept等词汇（receive又较accept），太多的被动式会把自己绕晕的。3.口语和医学术语的区分。不要用口语化的描述代替专业词汇，He got heart attack twice in the past. 就不如He experienced acute MI twice in the past正式，另一种相对的错误是是该使用口语化的词汇时（描述症状）用了专业词汇（体征），如将病人出现皮肤巩膜黄染中的黄染误用了黄疸jaundice，正确的用法应该是he got stained yellow on skin and sclera.以及不要在病历中使用一些情绪化的副词如Unfortunately， Surprisingly， To our surprise， Unexpectedly等等。此外还有一些注意事项，但是非英文病历写作独有，如何时用a何时用the，and， so及but等介词的用法等等，在此不再赘述。,History of past illness，至Impression部分的写法比较固定，相对较简单，主要是解决词汇问题。,Past illnessand Systemic review,A：HospitalizationB：IllnessC：TraumaD：OperationsE：Childhood diseases,Personal history,A：AppetiteB：Use alcohol，coffee，tea，tobaccoC：Sexual habitsAllergies：Hay fever，asthma，hives，food，skin，drugs,Marital History,A：Age and health of spouse； year marriedB：Ages and health of childrenC：Previous marriages,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（步伐） mental status: alert, obscure（不清楚的）, lethargy（昏睡）, coma cooperative,Physical examination,Skin and mucous: color (reddish, paler, cyanosis, yellowish, pigmentation) swelling, moisture, elasticity, bleeding, rashes, subcutaneous nodular, spider angioma（蜘蛛痣）, ulceration, scar. The location, size and shape should be recorded. Lymph note: systemic or localized lymph notes (submaxillary, 下颚；posterior auricular, 耳后的；neck, armpit, 腋窝；groin，腹股沟). Its size, number, tenderness, hardness, mobility, fistula（漏管）, scar etc.,Physical examination,Head and organsHead: its size, shape, tenderness, mass, hairEye: eyebrow（眉毛）, eyelash（睫毛）, eyelid,（眼睑） eyeball (protrude/突出, sunk/凹陷, movement, tremble/震动, strabismus/斜视), conjunctiva（结膜）, sclera(巩膜）, cornea/角膜 (size, shape, symmetry, light reflex, near reflex). Ear: discharge, hearing, mastoid（乳突）.Nose: abnormality; tenderness of maxillary sinus（上颌窦）, ethmoid sinus（筛窦）, frontal sinus（额窦）; exudation（分泌）, bleeding.,Physical examination,Oral cavity: odor, lips (color, swelling, ulceration, herpes simplex, pigmentation); teeth; gingival（齿龈）; tongue (mass, ulceration，coating of the tongue, mucus (rash, bleeding, ulceration); tonsils（扁桃腺）; pharynx（咽） etc. Neck: symmetry; texture (slightly flexed and cradled in the examiners hands); thyroid gland (size, hardness, tenderness, nodular, tremble, murmur); superficial venous distention; the position of the trachea.,Physical examination,Chest: configuration; symmetry; local protrude; tenderness; respiratory rate and pattern; abnormal pulsate（异常搏动）; breast (size, mass); venous distention,Physical examination,Lung: Inspection: respiratory movement; interspace of ribs; Palpation: the extent of chest excursion（移动）; vocal fremitus（语颤）; Speech creates vibrations that can be heard when one listens to the chest and lungs. These vibrations are termed vocal fremitus. When one palpates the chest wall while an individual is speaking, these vibrations can be felt and are termed tactile fremitus（触觉语颤）. Pleura friction（胸膜摩擦音）; subcutaneous crepitus（捻发音）.,Physical examination,Percussion: resonance tympany hyperresonance dullness flatness diaphragmatic movement Auscultation: breath sounds tracheal bronchial bronchovesicular vesicular,Physical examination,Heart: Inspection: apical impulse, or its location, area and intensity Palpation: assessing point of maximum impulse, thrills, fremitus Percussion: percuss the hearts borders, the relative dullness or absolute dullness borders Auscultation: the heart rates, rhythm, heart sounds, murmur（杂音）, abnormalities of the S1, S2, splitting of S2, systolic clicks, diastolic opening snaps, vocal fremitus, premature beats（早搏）,Physical examination,Radial artery (桡动脉): pulse rate, rhythm (regular or irregular), pulse deficit（脉搏短促）. The pulse may be described as normal, diminished, increased, or double-peaked. Peripheral vascular signs: capillary strike signs, bruits（杂音）, abnormal artery movement.,Abdomen,Inspection: symmetry, size, abdominal distention, pitting (concave abdomen), respiratory movement, skin lesion, pigmentation, surgical scar, umbilicus, hernia（疝）, body hair, venous distention and direction of blood flow, peristaltic waves（蠕动波); ecchymoses (淤斑) Palpation: the tenderness of abdominal wall, rebound tenderness, mass (location, size, shape, texture, tenderness, motion, mobility),Abdomen,Liver: size, character, surface, edge, tenderness, motion. Gallbladder: size, shape, tenderness Spleen: size, character, tenderness, surface, edge Kidney: size, shape, character, tenderness, mobility Bladder: distention (膨胀) costovertebral（肋椎的) angle tenderness,Abdomen,Percussion: liver dullness borders, hepatic tenderness over the right upper quadrant, shifting dullness (移动性浊音) Auscultation: bowel sounds(肠鸣音), vascular bruitsAnus and rectum: anal fissure (肛裂) anal fistula (肛瘘 ) pile(痔) digital rectal examination(肛指检查),Genitalia,Male: pubes(阴毛), penis(阴茎), glans(龟头) scrotum (阴囊), testicles (睾丸), epididymis(副睾), Female: External: pubes, vagina(阴道), urethral meatus(尿道口), hymen(处女膜), labia minora (小阴唇), labia majora (大阴唇), clitoris(阴蒂) Internal: ovary(卵巢), uterus(子宫), fallopian tube (输卵管),Physical examination,Spine: tenderness, abnormal spinal extension/rotation, lateral deviation Extremities: deformity, venous distention, stiffness, limitation of motion, joint, strength,Physical examination,Nervous system: biceps tendon reflex (二头肌反射) triceps tendon reflex (三头肌反射) patellar tendon reflex (膝腱反射) Achilles tendon reflex (跟腱反射) abdominal superficial reflex (腹部反射) cremasteric superficial reflex(提睾反射) test for abnormal reflexes: babinski sign, chaddocks sign, hoffmanns sign,Specialized subject: such as: surgery ophthalmology (眼科) gynecology (妇产科),Physical examination,Laboratory and other special examinations,Laboratory tests: record all those data that are associated with diagnosis, including three routing tests and other laboratory tests 24 h after admission. Special exam: gastroscopy, barium enema, X-ray etc.,Summary,Combining with the case history, physical examination and laboratory data, propose the evidences of diagnosis, and finally set up the diagnosis Preliminary diagnosis Signature or stamps,Common medical documents,Record of admission Record of the course of disease Record of consultation Record for transferring to new department Record of discharge Record of death Others,Record of admission入院录,The record of admission is the abstract form of full case record. The key points should be emphasized, and it should be written concisely(简明) or compendiously(简要), and should be finished with 24 h after admission by resident The chief complain and present illness are written in the same form as full case record, the others could be written in the short form, without the abstract.,The format and content of record of admission,General information of the patient Chief complaint Present history of illness Past history in summary Physical examination Vital signs General appearance and systemic organs Laboratory tests Preliminary diagnosis Signature,Record of the course of disease病程记录,It records the progression and treatment of the whole courses of patients disease during ones admission. It should be recorded with trueness, promptly, with prospective analysis. It actually reflects the quality of the medical treatment. It can be written once a day according to the changes of the disease. For those severe cases, it should be written several times per day. For those patients with mild illness, however, it could be written every 23 day.,The content of records are generally including,The patients complains (about his/her discomfort, moods, physiological status, food, sleep, relieve oneself, those can be further selected according to the need for the progression of the disease. The changes of disease, including signs and symptoms, or any new discovery, the results of various laboratory or other adjuvant examinations, the analysis, evaluations, or remarks on those data.,The content of records are generally including,The records of various manipulations, such as plural puncture, abdominal puncture, lumber puncture, endoscopy, cardiac catheter exam, various radiography. Reinforce or amend the clinical diagnosis, amend the evidences for the diagnosis. The opinion of senior doctor about the diagnosis and differential diagnosis. The treatment, drug use and its efficacy or side effects. Opinion of consultation of other department.,The content of records are generally including,Information from patients relatives (their hope, desire, and reflection; the information that the doctor induced to the patients relatives Monthly brief phase summary Time of record and signature,The first record of the course of disease 首次病程录,The first record of the course of the disease should be recorded at the same day as admission, its content and format are different from that of other record of course of the disease, including patients name, sex, age, chief complain, prominent signs and symptoms, results of those adjuvant examination, that are highly summarized and emphasizing the key profiles.,The first record of the course of disease首次病程录, Propose the preliminary diagnosis, differential diagnosis and their evidences, based upon above data. Propose some other special examinations in order to further confirm the diagnosis Propose the treatment and diagnostic planning according to the actual situation of patients illness on admission,Record of consultation 会诊记录,If the patient presents other system disease, or symptoms difficult to diagnose, other specialist may be invited for consultation. In general, the consultant opinion will be written in consultant sheet. The consultant opinion includes brief description of case record, specialized examinations, the analysis and diagnosis of the disease, propose his opinion for further more precise examinations.,Record of consultation,If the opinions are collectively, record all those doctors participating the consultation, their analysis, examination, and treatment.,Record for transferring to new department转科记录,During the periods of hospitalization, the patient may present symptoms of other systems (department). With the approval of doctor of other department, the patient can now be transferred to the new department. It can be written in the record of the course of diseases sheet. The content may include the major cause of disease, treatment, the reasons for transferring, the precaution notes etc.,Record for transferring to new department,If the patient is transferred from other department, resident should write the record of transferring, the content of the record is similar to that of record of admission.,Record of discharge出院记录(出院小结),When the patient is going to be discharged, the record of discharge should be written, and give to the patient on the data of discharge. The content includes: Name, sex, age, diagnosis on admission, data of admission, diagnosis on discharge, data of discharge, days of hospitalization. Various numbers of special examination (number of hospitalization, number of X-ray, CT, pathology, EKG etc.,Briefly introduce the reason of admission, present illness, the data of major examinations, the progression and treatment of the disease during hospitalization. The condition of patient on discharge, including signs and symptoms, results of major examination and treatment (recover, improve, no effect, exacerbate, complication). The treatment advice on discharge, notes for precaution,Record of discharge出院记录(出院小结),Record of death死亡记录,The record of death should be recorded immediately after death of patient. The content and format of death record are similar to that of discharge record. It includes case summary, hospitalization, diagnosis and treatment, the causes for diseases progression, the rescue course, time of death, causes of death, and final diagnosis.,Record of death死亡记录,For all death patients, particularly those cases the diagnosis are uncertain, one should persuade the relatives of death patient to perform the autopsy, the anatomicalpathological results will be also recorded.,Others,The routine medical documents also include summary of preoperation, record of post-operation, record of surgery etc. The format is consistent with the record of course of disease. Summary of pre-operation may emphasize to record the disease condition, reasons of operation, types of operation, the possible complications/situations occurred post-operation, and methods toward to these complications.,Others,Post-operation records should record the condition of surgery, findings during surgery, name of surgery, disease progression during surgery, types of anesthetics, response of anesthetics, treatment advice for post- operation etc. The record of surgery should be writt