论文部分内容阅读
本书参照全军新编《常规》的规定结合实例,由上海长征医院各专科医师百余人执笔、楼方岑教授主编。全书分五章:第一章列出28个专业的病历,每一病历包括入院记录、入院病历,诊断讨论与诊疗计划、病程记录、巡诊记录、手术记录、麻醉记录、转科记录、病案首页等;第二章是各专科室的会诊、检查、治疗申请单和报告单20多种;第三章是各种护理记录及护理病历;第四章是各专业科室的54个门诊与急诊记录,以及门诊诊疗申请单、记录单、转诊单、诊断证明、住院证、处方等;最后是13种为写好
This book refers to the entire army’s new “regular” provisions combined with examples, by the Shanghai Changzheng Hospital, more than 100 specialist doctors, Professor Fang Fangyi editor. The book is divided into five chapters: The first chapter lists 28 professional medical records. Each medical record includes admission records, hospital records, diagnostic discussions and medical plan, course records, medical records, surgical records, anesthesia records, transfer records, and medical records. The second chapter is more than 20 kinds of consultations, examinations, treatment requisitions and report forms in each special room; the third chapter is a variety of nursing records and nursing medical records; the fourth chapter is the 54 outpatient and emergency records of various professional departments , And outpatient medical treatment application form, record sheet, referral form, diagnosis certificate, inpatient certificate, prescription, etc.; finally, 13 kinds are written