Taizhou and open (hospital) outpatient (medical) full set (for leave single / inpatient) diagnostic proof electrical .v [synchronous Fu Shen - 155 Fu 7637 Fu 3781] zhang "honest services"
The early Han Dynasty famous physician Chunyu Yi, is China's first invention and use of medical doctor. Chunyu Yi studious, enthusiastic studying medicine, was "recipe" from the teacher Kung-optics, "plan", and take from the public learned of the Yellow Emperor Yang Qing, Que veins books and colored diagnostic
methods, medicine increasingly profound. In the process of long-term practice, he deeply felt: patient's chief complaint, if there is no record while the doctor alone is not enough memory (memory because doctors are not allowed, often give the treatment difficult). Chunyu Yixiang Dao a good way
- in medical treatment, a detailed record of the eleven down the patient's name, address, conditions, prescriptions, diagnosis and treatment of date; at the same time, the cure and deaths are also recorded in detail. After a period of practice, Chunyu Yi was doing this for the diagnosis and treatment has
benefits. And this record is Chunyu Yi called "diagnosis membership." Later, many doctors to follow suit, because it is dedicated to recording the history of the patient, so the doctor called "records."
Modern, medical record is the sum of the text form of medical personnel in a medical procedure activities, symbols, graphics, video, and other data slices. The main implemented by clinicians and nursing, medical technicians and other medical personnel. According to their interrogation, physical examination, laboratory examinations
information, diagnosis, treatment, care and other medical activities obtained through induction, analyze, organize and complete medical records. Medical records not only the disease, but also to record and analyze physician of the disease, diagnosis, treatment, care process, estimation of prognosis, as well as all levels of
advice and consultation of a physician rounds. As the medical records of patients throughout the treatment process of the original records, records of patients admitted to the hospital after by the patient or person, accompanied by statements disease, health care workers to patients for diagnosis, treatment, physical and chemical examination, the patient was discharged until death or the whole
truth process. Therefore, the actual recording both medical condition, but also health care, quality of care and reflect the academic level.
Chief Complaint: (1), refers to the major complaints of patients admitted for treatment of symptoms and signs and their time of occurrence, the nature or extent of, and other parts, to produce a first diagnosis based on complaints. To complained concise language, generally preferably not more than 20 characters. (2), not to diagnose or
test results chief complaint content (determined asymptomatic exceptions). When more than one complained of, or time of occurrence may have primary and secondary listed separately.
Past medical history: past history means the patients before the onset of this disease and the health situation, especially with the current disease closely related disease, chronological record. The main contents include: (1), previous general health. (2), whether suffered from infectious diseases, where
disease and other diseases, date of onset and treatment conditions. Previously the patient's illness, the diagnosis of disease name certainly were available, but it should be in quotation marks; those who are not sure of the diagnosis, outlining its symptoms. (3), with or without vaccination, trauma, surgery, as well as pharmaceutical, food and
other contacts thereof history of allergies and the like.