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目的对病案中的新病种、疑难复杂疾病、急危重症,新的医疗、技术、设备、护理的实践,包括疗效的观察、经验教训等进行总结,做成“特殊病案总结”,以区别于普通病案,让更多的人共享,从而提高病案的利用价值。方法由主管医师从出院病案中提取“特殊”,副主任医师以上签阅生效,附在出院病案后面并输入计算机处理(为维护病人隐私可不输入姓名)。结果从病案的各组成部分入手,分析了特殊病案常常会在哪些方面“特殊”。结论“特殊病案总结”能对出院病案的利用起到提纲挈领的作用,特别是经过计算机处理以后,能使长年沉睡的大量出院病案更好地为医学服务。
Objectives To summarize the new diseases, complicated and difficult diseases, critical illnesses, new medical treatment, techniques, equipment, and nursing practices in the medical records, including the observation of curative effects, lessons learned, etc., and to make “special case summary” to distinguish In ordinary medical records, let more people share, so as to increase the value of medical records. Methods: The competent physician extracted “special” from the discharged medical records. The deputy chief physician signed the above and went into effect. It was attached to the discharged medical record case and entered computer processing (in order to maintain the patient’s privacy, no name could be entered). As a result, starting from the various components of the medical record, it was analyzed in what areas special medical records are often “special”. Conclusion The “Summary of Special Cases” can play a role in promoting the use of discharged medical records, especially after computer processing, which can enable a large number of hospital discharge cases that have been sleeping for many years to better serve the medical services.