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1、lHISTORY RECORDlThe clinical record documents the patients history and physical findings.It shows how clinicians assess the patient,what plans they make on the patients behave,what actions they take,and how the patient responds to their efforts.l1.Diagnosis and treatment purpose An accurate,clear,we
2、ll organized record reflects and facilitates sound clinical thinking.It leads to good communication among the many professionals who participate in caring for the patient l2.Teaching and research purposel3.Medicolegal purposes lWhen creating a record,you do more than simply make a list of what the p
3、atient has told you and what you have found on examination.You must review your data,organize them,evaluate the importance and relevance of each item,and construct a clear,concise,yet comprehensive report.l1.Order is imperativel2.Keep items of history in the history l3.Describe specifically any pert
4、inent negative information l4.Data not recorded are data lost l5.Use short words instead of long and probably fancier ones when they mean the same thing l6.Be objectivel7.You should write the record as soon as possible l1.To be well organized and canonicall2.No much erasion and gride could be done i
5、n the history recordl3.To be objective and accuratel4.Using professional term to record instead of folksayl5.Remember to have your signaturel1.Biographical data Biographical information of patient should include his full name,age(date of birth),sex,race,occupation,nationality,marital status and perm
6、anent home address.Also,the date of admission,the time at which you took the history,the source of history and estimate of reliability should be involved.l2.chief complaint The chief complaint consists of main symptom(s)and duration.It should constitute in a few simple words the main reasons why the
7、 patient consulted doctor and should be state as nearly as possible in the patients own wards.In general,the chief complaint should include age,sex,complaint,and duration of the complaint.It should no included diagnostic terms or disease entities.For example:”This 70-year old man has had short breat
8、h for a week.”l3.History of present illness(HPI)The history of present ill ness should be a well-organized,sequentially developed elaboration of his chief complaint(s)on its various characteristics:date of onset,character of complaint,mode of onset,course and duration,location,relationship to other
9、symptoms,bodily function and activities,exacerbation and remissions,and effect of treatment.l4.Past history(PH)It should include a review of all past ill nesses,surgical procedures,and injuries,and allergy history(medicine,food),which are particularly related to the present illness.l5.Review of syst
10、em(ROS)The purpose of sys tem review is twofold:a thorough evaluation and a double check prevent omission of significant data relative to the present illness.The review is a comprehensive account of all complaints referable to each body system progressing in a logical manner from the head toward the
11、 feet,including respiratory system,cardiovascular system,digestive system,Urinary system,hemopoietic system,endocrine system,nervous system and skeletal system.l6.Personal history(social and occupational history)It includes personal habits(smoking,alcohol drinking),business life,sex life,occupation(
12、exposure to certain irritating agents),condition of work.l7.Marital history It includes data concerning the health of mate,sexual adjustment,the number of children and their Physical status,and the general social adjustment within the family.l8.Menstrual history(for female patients)Age of onset,inte
13、rval between periods,duration,amount and character of flow,concomitant symptoms,date of last menstruation,age of menopause.l9.Childbearing(reproductive)history Age and date of pregnancy(ies)and childbirth(s).Date of artificial or natural abortions,stillbirths,operative delivery,puerperal fever.Metho
14、d of family planning,the possible factors of infertility(also for male patients).l10.Family history(FH)The health status of the patients family(mother,father,siblings and children)and if died,the age and cause of death should be recorded,such as diabetes,hypertension,cancer,obesity,allergic disorder
15、s,coronary artery disease and mental illness.l11.Physical examination(PE)The recording of Physical examination should follow a logical sequence as follows:vital signs,general status,skin,nodes,head,neck,chest,lungs,heart and blood vessels,abdomen,genitalia,rectum,spine and extremities,nervous reflex
16、es.l12.Laboratory tests and instrumental examination The findings of them onkly serve to confirm what you have found on history and Physical examination.The routine laboratory studies include blood,urine and stool tests,electrolytes,X-rays and ECG.l13 Summaryl14.Primary diagnosis As the results of differential analysis of a number of significant data,a primary diagnosis could be established.It consists of etiologic diagnosis,pathological diagnosis,pathophysioloical diagnosis(stage or period and
