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題 名 | 如何寫好病歷=How to Write Medical Records |
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作 者 | 賴其萬; | 書刊名 | 病歷管理期刊 |
卷 期 | 5:1 民94.10 |
頁 次 | 頁56-63 |
分類號 | 419.26 |
關鍵詞 | 病歷記錄; 病歷記錄品質; Medical record; Medical record quality; |
語 文 | 中文(Chinese) |
中文摘要 | 病歷的書寫是臨床工作十分重要的一環。一份用心寫出的病歷需要醫生仔細的詢問病史、身體檢查,再加上其專業的整理、分析,對於病人的醫療影響至鉅。這種情形尤其在病人需要照會其他醫生或轉到其他醫院時,醫療訊息的溝通更是重要。病歷的書寫包括住院病人之入院病歷、病程紀錄、出院摘要、病房照會病歷、門診病人之初診病歷、複診病歷、以及給轉診醫師的介紹信或回函。本文就病歷寫作的要項逐一討論,最後並簡單討論有關病歷書寫是否應該使用中文的爭議、英文病歷書寫方面所常遭遇到的困難以及病歷電腦化的隱憂。 |
英文摘要 | Writing medical records is a very important task in clinical care. A good medical record should document careful history taking and physical examinations, be well organized, and include analysis. The effect of the medical record upon a patient's care its tremendous, and communicating medical information becomes particularly important when it involves consulation or transfer. Writing medical records involves inpatient records such as admission note, progress note, discharge note, and consultation note, as well as outpatient reocrds such as first and return visit notes, and referral notes or responses to the referral. This article discusses the different steps involved in writing medical records and touches briefly on the issues of whether we should write medical records in Chinese, the difficulties often encountered when writing medical records in English, and common concerns about computerized medical records. |
本系統中英文摘要資訊取自各篇刊載內容。