The case history writes the norm to revise Improve the link record incident of doctors and patients' dispute

The case history writes the norm to revise Improve the link record incident of doctors and patients' dispute
The electric websites of Chinese Health Ministry give notice today on February 4 in www.chinanews.com, requires from March 1, 2010, " basic norm that the case history writes " after it is revised and improved that every medical organization implements in the whole country, issued in 2002>(Defend medicine and send ( 2002) The 190th) Abrogate at the same time.
Write the behavior, go on the detailed norm " case history write basic norm " that implement to every case history of medical organization, in order to improve the quality of case history, ensure the medical quality and security. Among them, to doctors and patients' both sides' links that misunderstand, dispute incident, have carried on the clear norm, for instance: Need to check and record after the fixed operation, " letter of consent of operation " Not only again " Sign " When.
The case history needs to write according to the fixed content It needs to guarantee to record and can clearly distinguish originally to correct error
" norm " is clear at first, the case history refers to the total of the materials of characters, symbolling, charting, imaging, slicing etc. that the medical worker formed while medical treatment is movable, including the door is (urgent) Examine the case history and case history in hospital. Compared with trying edition before this, in " objective, true, accurate, prompt, intact " Foundation have increase " The norm " Write require.
" norm " is especially pointed out as to the situation that the case history may present the wrongly written character in the course while writing, appear wrongly written character, should draw at wrongly written character with double-line, keep, record clearly, can distinguish originally, and mark out and revise time and revise people and sign. Can't adopt the method of shaving, glueing, scribbling etc. to conceal or remove the original writing. Emphasize, the medical workers of higher authorities examine the responsibility which revises the case history that the subordinate medical worker wrote at the same time.
" norm " requires, the case history should be written according to the fixed content, and is signed by the corresponding medical worker; Practising the case history that the medical worker, medical worker in probationary period wrote, the medical worker who should register through this medical organization checks, revises and signs; Receive a training of medical worker by medical organization until their competent at the intersection of professional work and actual conditions this, write the case history after asserting. Write and use Aeabic numeral to write date and time without exception, adopt for 24 hours and make the record.
The door is (urgent) Examining the case history needs to do well and leave the view record Examine a doctor to finish in time from meeting
" norm " points out, the door is (urgent) Examine the content of the case history to include the door is (urgent) It is (urgent) to examine the home of case history (door Examine the front cover of manual) , the case history is recorded, laboratory test report (survey report) , medical image check materials,etc., should examine a doctor to finish in time when the patient goes to a doctor by answering.
And require, the door is (urgent) It needs to record patient's name in detail to examine the home of case history, gender, born in project contents such as the date, nationality, marital status, job, office, address, drug allergy history,etc., the manual front cover content of the clinic should include projects such as patient's name, gender, age, office or address, drug allergy history,etc..
Leave whom view record, write as to emergency call, " the norm " point out emergency call leave view record it is the intersection of emergency call and patient that need record stay in hospital, because of condition, record condition changing and measure of making a diagnosis while observing especially, the record is brief and concise, and mark out patient's whereabouts. While rescuing the critical patient, should write and rescue the record. The door is (urgent) Examine and rescue and record and write the content and demand to rescue and record and write content and requirement to carry out according to the case history in hospital.
" intern " Can record the daily course of disease Must be managed a doctor and signed
About case history in hospital to write the content, " the norm " demand, include, in hospital home of case, admitted to hospital recording, recording, letter of consent of surgery, letter of consent of anaesthesia, blood transfusion of course of disease and treat the letter of consent in the know, check specially (special treatment) Letter of consent, critically ill (serious) The notice, doctor's order form, auxiliary examination report that checks materials, pathologic materials etc. in single, the body temperature form, medical image. Among them, as to " medical history now " , " history previously " With " personal history " , " family's history " Wait for the content to make carefully to require, for instance, need to record the patient's birthplace and reside the ground for a long time, hobby such as habits and customs and having smokelessly, wine, medicine, and the job and condition of work,etc..
After patient admitted to hospital condition their and make a diagnosis continuity of course record, the intersection of course of disease and record. " norm " is required through managing the record of first course of disease that the doctor or doctor on duty wrote, should finish in the patient is admitted to hospital for 8 hours, the content includes the case characteristic, plans to examine and discuss (diagnoses basis and differential diagnosis) , make a diagnosis plan,etc..
The daily course of disease is recorded and managed a doctor to write, it is the regular, continuity record of the course of making a diagnosis to the patient in hospital. While writing, indicate and record time at first, get up another conduct and record the concrete content. Should write the record of course of disease to the critically ill patient at any time according to the condition change, at least once every day, record time should be to minute specifically. To the seriously ill patient, record record of course of disease once at least 2 days. Patient steady to condition, record first record of course of disease 3 day while being at least.
" norm " especially proposes, the daily course of disease can be written from practising the medical worker or medical worker in probationary period too, but should be managed a doctor and signed.
Operation " every link " Need detailed record Prevent the patient from leaving the gauze syringe needle in the body
" norm " requires, all kinds of implemented in clinic diagnosis create making a diagnosis, need to write at once after finishing. The content includes operating name, operating time, operating sequence, result and patient's general situation, is it smooth and having bad reactions, postoperative attentive matters and explaining to the patient to record the course, the operation doctor signs.
Compared with trying edition, " the norm " increase anaesthesia visit, look at, record in front of the skill and operation verify, record safely and operation check, record and anaesthetize, visit, look at content of recording etc. while being postoperative. Among them, verify needing by operation doctor, three sides of doctor and circuit nurse of anaesthesia to contents such as the operation detail,etc. safely before the skill, the blood transfusion patient's blood group, checking, confirming and signing with blood volume,etc.; The operation is checked
Finished immediately after the operation finishes by the circuit nurse, must check to check to various apparatus and dressing quantity used in the skill, and circuit nurse and operation apparatus nurse sign.
" letter of consent " Subdivide and increase the classification Do not only sign " Sign "
This " norm " is the a bit more most light, it is to " letter of consent " Content make" Humanization " Revise, except keeping " letter of consent of operation " Outside, have also increased " anaesthetize the letter of consent " , " blood transfusion treats the letter of consent in the know " With " checking specially, letter of consent of special treatment " . Must inform patient about the relevant situation planned to treat, risk and complication,etc. that may appear (concrete requirement through managing a doctor, see every therapeutic project) ,Write comments and sign one's name and sign, manage into doctor, sign and fill in date by patient.
Compared with trying edition, " norm ", to " letter of consent " Word change into " The patient signs the medical document agreeing " ; The ones that try edition " The patient signs " Change into " a patient writes comments and signs one's name and signs " .
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