首次病程记录书写的探讨

首次病程记录是指患者入院后由经治医师或值班医师书写的第一次病程记录,内容包括病例特点、初步诊断、诊断依据、鉴别诊断和诊疗计划,不是入院录的简单重复。首次病程记录书写有3个基本要求,如书写者、书写时间和记录时间的限定。首次病程记录标题、书写者限定、书写者签名位置和记录时间的书写是书写过程中存在争议的地方;诊断与诊断依据、鉴别诊断与鉴别依据和诊疗计划是书写时问题存在最多的部分。对争议和问题进行了深入探讨,并提出了合理的对策,为规范书写首次病程记录提供参考。

Discussion on the Writing of the First Course of Disease Record

The first course of disease record is the first record written by the doctor or physician on duty which includes the case characteristic, initial diagnosis, diagnosis, differential diagnosis and treatment plan, not simple repetition of the admission record. The first course of disease record in writing has 3 basic requirements, such as writer, writing time and the limit of record time. The controversies parts during writing are the title of first course of disease record, the limit to writer, signature place and the record time; the parts of existing most prohlerns am diagnosis, basis of diagnosis, differential diagnosis, differential basis and treatment plan. It deepen discusses the controversies and problems and puts forward reasonable countermea- sures which provides references for standardizing the first course of disease records writing.