论文部分内容阅读
现病史是病历记录的核心内容,也是病历质量考核主要内容之一。书写好现病史应该按照现病史书写顺序和疾病发展衍变过程进行书写,不能遗漏每项内容。现病史内容过于简单、杂乱无章等现象是书写中的常见问题,应该给予防范。鉴别资料是现病史书写的难点,鉴别资料含义的明确和鉴别疾病的选择是鉴别资料书写的关键。书写技巧的掌握将有助于书写好现病史。
Current history is the core content of medical record, but also one of the main content of medical records quality assessment. Written history of the current illness should be written in accordance with the order of the current medical history and the evolution of the disease development process, we can not omit each content. Current history of the content is too simple, disorderly phenomenon is a common problem in writing, should be given protection. Discrimination data is the difficulty of writing the current history of the disease, identify the meaning of the data clearly and identify the choice of disease is the key to identifying data writing. The mastery of writing skills will help to write good medical history.