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| 关于主诉定义和书写要点的讨论 | |
| 引用本文： | 李小平,耿建英,侯树忠,周素鲜,刘福勇,王卉. 关于主诉定义和书写要点的讨论[J]. 中国病案, 2006, 7(4): 4-6 |
| 作者姓名： | 李小平 耿建英 侯树忠 周素鲜 刘福勇 王卉 |
| 作者单位： | 050082,石家庄,解放军白求恩国际和平医院 |
| 摘 要： | 文章提出了在医院医疗服务范围和项目不断拓宽的情况下,现行病历书写规章制度中有关“主诉”的定义和书写要求也应进一步修改和拓宽。作者根据多年做临床质量控制工作和住院病历检查的经验,结合国内医学文献中部分专家的意见,对主诉的书写要点和常见问题进行了分析、总结。 |
| 关 键 词： | 病历书写 主诉 定义 |
A Discussion on the Definition of the Chief Complaint and the Main Points of Writing a Medical Record |
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| Li Xiaoping,Geng Jianying,Hou Shuzhong,Zhou Suxian,Liu Fuyong,Wang Hui. A Discussion on the Definition of the Chief Complaint and the Main Points of Writing a Medical Record[J]. Chinese Medical Record, 2006, 7(4): 4-6 | |
| Authors: | Li Xiaoping Geng Jianying Hou Shuzhong Zhou Suxian Liu Fuyong Wang Hui |
| Abstract: | The rules and regulations of documentation of the medical record concerning the definition of the chief complaints and their criterion should be changed and developed in order to adapt the constant changing of medicine service. Combining the opinions declared in domestic medical literatures which brought forward by some specialists, based on personal experiences of clinical quality control and examination on the medical records, the author summarizes the main points of chief complaints and the common problems about them. |
| Keywords: | medical record chief complaint definition |
| 本文献已被 CNKI 维普 万方数据 等数据库收录！ | |