Since 1981 Health School

"The weather is warm today. I went with Dr. Wang to make rounds. Dr. Wang asked how the patient was doing. The patient said he was doing better. Dr. Wang smiled, and the patient also laughed..."

As soon as Chen Qi finished reading aloud, everyone in the gazebo was out of breath from laughing. Bian Hongen leaned on Li Sujuan's body and scolded while laughing:

"Sujuan, are you writing a composition for elementary school students? I'm so ridiculous, where is the course record?"

Li Sujuan's face had turned into a red apple, but she still refused to admit it, and murmured in a low voice:

"I just wrote down the scene of the ward rounds at that time truthfully, and I didn't make it up at all."

Chen Qi laughed for a long time, cleared his throat:

"You did write it down truthfully. If it is a student composition, it is fine, but as a medical professional document, it is not acceptable. A formal record of the course of the disease should include the changes in the patient's condition, important auxiliary examination results, and clinical significance.

In addition, there are opinions of superior doctors on ward rounds, consultation opinions, analysis and discussion opinions of doctors, diagnosis and treatment measures taken and their effects, changes of doctor's orders and reasons, important matters notified to patients and their close relatives, etc. "

The students stopped laughing when they heard that Squad Leader Chen started to give a lecture. They all lowered their heads and took the time to record the first sentence Chen Qi said. Everyone looked very serious.

"For this record of the course of the disease, you can write like this: the patient has been in the hospital for two days, his condition is stable, and he still has a low-grade fever of about 38°C, and the joint swelling and pain have not aggravated.

This morning, Dr. Wang made a ward round. After listening to the medical history report and physical examination, he believed that the symptoms were swelling and pain in the joints, lower knots, rapid sinking, and st-t changes in the electrogram. He agreed with the original diagnosis and treatment.

In view of multiple nodules in the disease, 24-hour urine uric acid quantification and joint photography were ordered to rule out pain. Anti-humidity treatment has been started, and changes in the condition should be closely observed. Follow the instructions above. "

Chen Qi added:

"If there is any auxiliary examination report on the day, the results should be written in the course record in time, so that the superior doctor can see the course of the disease at a glance, and know the changes in the patient's condition over the past few days.

At the same time, it is also a piece of evidence, so that in case of medical disputes in the future, the doctor can't explain clearly, so everyone must record it carefully, don't be afraid of trouble, and at the same time, the writing must be standardized, so that Li Sujuan's mistakes will not be repeated. "

As soon as the words came out, the students in the gazebo also nodded vigorously. Everyone felt that what they were facing was not a classmate, but a teacher.

Chen Qi took Hu Jie's medical records, and then rolled his eyes suddenly:

"This is a consultation form. Listen, everyone thinks it's right to write it like this: the reason is written on the consultation form: the patient complains that he is unspeakably uncomfortable."

Hahaha, the gazebo burst into laughter again.

Chen Qi grabbed Hu Jie, "Come here, Doctor Hu, if you were a consulting doctor, would you kill this intern who wrote the application form?"

Hu Jie was also a little bit embarrassed: "Well, at that time, the patient just said that he felt unspeakably uncomfortable."

After Chen Qi looked through the entire medical record, his voice raised a bit:

"The consultation form is to be sent to the consulting doctor, so it is necessary for the consulting doctor to know roughly what the condition is after seeing the chief complaint. This is very important, especially for emergency consultations, it must be concise and to the point.

As the doctor who issued the consultation invitation, you can’t tell what’s wrong with the patient, so the other doctor can’t do anything, and it’s impossible for the other department to send a professional doctor to participate in the consultation. The delay is still the patient’s condition.

Therefore, for a correct consultation form, you must fill in the application consultation items of the application form in detail, briefly describe the condition of the disease and the diagnosis and treatment, and the reasons for applying for consultation. Consultation department.

It should be noted here that the general consultation will be completed within 48 hours. For minor illnesses that require special examinations, you can make an appointment for a specialist examination. The emergency consultation in the hospital must be in place within 10 minutes. "

Chen Qi turned over the medical records brought by the students, pointing out the problems one by one.

The effect of this kind of practical exercise is far better than the theoretical teaching in the classroom. Everyone has learned how to write medical records and course records. Why do you still make mistakes after you really get started? This is caused by inexperience.

Chen Qi has been an intern dog for many years, and he personally teaches students after work, so it is a piece of cake for how to teach interns relevant knowledge.

In the dean's office on the third floor.

After lunch, Dean Guo Yuanhang was about to close the curtains and rest for a while, when he suddenly heard bursts of laughter coming from the garden downstairs.

Curiously, he stretched out his head to have a look, and saw a group of medical school interns who had just registered, discussing something enthusiastically in the garden, and each of them held a medical record iron folder in their hands.

Dean Guo felt a little curious. Anyway, he had just finished lunch, and he wanted to take a walk after dinner to help digestion, so he picked up his coat and went downstairs.

When he arrived in the garden, he didn't bother the group of students, but stood in a corner, just in time to hear the conversations of the interns.

Dean Guo was surprised to find that these interns were discussing the standardized writing of medical records.

What surprised him even more was that there was no teacher teaching at the scene, but the intern who pointed out the skull base fracture yesterday was helping the students to point out the mistakes and shortcomings one by one.

Dean Guo couldn't help looking at Chen Qi a few more times, thinking:

The same interns, the same class, the same age group, how can there be such a big gap? This kid doesn't even look like a student, he is clearly a veteran doctor with rich clinical experience.

At the same time, Dean Guo thought about yesterday's skull base fracture diagnosis topic, and strengthened his mind. When the internship is over, he must send this kid to the People's Hospital.

Chen Qi didn't know that he was "simple in the emperor's heart", he was still teaching his classmates how to write down medical records and related documents correctly.

At this time, Dr. Li Jun from the Department of Surgery was passing by the garden with Zhang Jun and Ai Kelong. After hearing the laughter, he glanced casually and saw the intern who made him unable to come down from the stage yesterday. It wrinkled up.

Zhang Jun was very good at reading his face, so he walked over slowly:

"Hey, students study very hard. You are still discussing problems without taking a break at noon. What are you discussing? Oh, medical record writing? My God, you can't do such a simple medical record writing, right? The teaching quality of your medical school Is it that bad?"

As soon as this remark came out, it immediately aroused public outrage!