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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。
The first course record refers to the first course record written by the attending physician or attending physician after admission. The record includes the characteristics of cases, preliminary diagnosis, diagnosis basis, differential diagnosis and treatment plan, and is not a simple repetition of admission record. There are three basic requirements for the first course record writing, such as the writer, the writing time and the recording time. The first record of disease course title, limit of writer, position of writer and signature of writing time are the controversial points in the writing process. The basis of diagnosis and diagnosis, the basis of differential diagnosis and identification and the plan of diagnosis and treatment are the most existing problems in writing. In-depth discussion of the controversy and issues, and put forward a reasonable countermeasures, to provide a reference for regulating the writing of the first course record.