论文部分内容阅读
疾病是复杂变化的,世界上没有完全相同的两个患者,但是疾病诊断是有路径可循的,快速而准确的临床诊断是医疗过程的基础和前提,内科疾病门、急诊临床诊断路径是为简便、快速、全面、正确进行内科临床诊断而设计的,旨在成为卫生部内科疾病临床路径的急先锋和有效补充,传统的门诊病历只是提示到要记录主诉、现病史、既往史、查体、诊断、处置原则或者仅仅为一张空格纸,临床医师在记述传统门、急诊病历时是根据医学经验进行的,记录的病历质量不一,我们需要格式统一方便快捷的制式表格来完成这项工作,为内科临床医师门、急诊工作提供方便,更为年轻医师养成简便快速全面的思维习惯提供有效途径。
The disease is complex and varied, there are not exactly two patients in the world, but the pathological diagnosis is a follow-up, rapid and accurate clinical diagnosis is the basis and premise of the medical process, medical disease door, emergency clinical diagnosis path is Simple, rapid, comprehensive and accurate clinical diagnosis of internal medicine designed to become the clinical pathways of the Ministry of Health clinical vanguard and an effective supplement, the traditional outpatient medical records only prompted to record the main complaint, history of illness, past history, physical examination , Diagnosis, treatment principle or just a space paper, clinicians in the traditional medical records, emergency medical records is based on medical experience, the records of the medical records of different qualifications, we need a unified and convenient standard form to complete this Work for the clinician physicians, emergency work to provide more convenient, more young physicians to develop simple, quick and comprehensive thinking habits provide an effective way.