外科病案书写要点探讨

外科病案在书写中与内科病案有许多不同,通过日常对外科病案检查中发现的许多共性问题进行梳理,并探讨了外科病案书写要点。指出书写外科病案要注意体现出外科疾病发生发展及转归特点、重视内科疾病对外科疾病的影响、专科体征描述要详实、注重饮食睡眠对外科病人的影响、注重术前小结及术前讨论的书写、注意把握手术适应症、注意规范术后首次病程记录。

A Discussion on Writing Key Points in Surgical Medical Records

There are a lot of differences between surgical medical records writing and internal medical records writing. Through the examination for surgical medical records in daily work, this paper summarized many common problems and discussed writing key points in surgical medical records. It points out that surgical medical records should embody the occurrence, development and prognosis characteristic of surgical diseases and focus on the effect of surgical diseases to internal diseases with detail physical signs; meanwhile it should pay attention to the effect of diet and sleep to surgical pa- tients, the writing of pre-operation summary and pre-operation discussion, operative indication and standard of first disease course post-operation.