Medical record

2021-01-26 12:00 AM

If the patient has been sick for a long time, has come back again, has to be hospitalized many times, this time the patient is hospitalized with the same expression as always before the appearance

Administration

Full name: Gender Age

Job.

Address.

Date of admission: Date, time

Contact person

Asked the disease

The reason for admission

Symptoms should be separated by commas or hyphens, not with a plus sign between symptoms

Medical history

Detailed reasons for admission.

The sequential course of these symptoms and the interplay of symptoms together.

What pathological manifestations appear first?

What was diagnosed, where?

What treatment was given, for how long?

What are the results, what symptoms are left / gone?

Before getting to the upline is diagnosed what, degree

Attention:

Describe the above developments sequentially, by administrative levels in health (village> hamlet> commune> district> province> city> central)

If the patient has a long-term illness, relapses, has to be hospitalized many times, this time the patient is admitted to the hospital with the same expression as always before the manifestation of this episode is described in the proximal section. history.

Prehistoric

Myself, family, close friends.

Diseases already acquired.

Present

Functional, subjective symptoms of the patient answering questions of the physician at the examination

Medical examination

Body

8 main parts must be examined and described in order:

Mental condition

Skin, organized under the skin.

Mucosa

Hair, hair, and nails

Creek

Thyroid

Body temperature

Pulse, blood pressure

Entity

Look, touch, knock, listen.

Description of the fourth: Diseased organs> circulation> respiratory> endocrine> digestion> kidney - urinary> muscle - bones - joints> nerves and other specialties (if any). 

Summary of preliminary medical records

Male / female patient, age, occupation (if related to disease).

How long are sick.

Hospitalized stars.

What is special about the physical examination, is description of symptoms, syndrome (if any), state symptoms (+) to confirm the diagnosis, and symptoms (-) contribute to the identification and category minus.

Initial preliminary diagnosis.

Subclinical

Proposal of solutions, tests, exploration ... is to clarify.

Blood tests

Record in order of results to help predetermine diagnosis, and then in the order: cytological, biochemical, bacterial ...

Urine test

Test for biochemistry, cells, bacteria.

Other basic tests

X-ray standard lung, electrocardiogram ...

Exploration and testing of a specialized nature

Respiratory: Respiratory function, contrast bronchoscopy, chest CT scan, bronchoscopy, pleural puncture, pleural fluid test, pleural biopsy ...

Cardiovascular: Electrocardiogram, exercise testing, Cardiac Doppler ultrasound, cardiac catheterization ...

Endocrine: Test for hyperglycemia, fasting test, ultrasound of the thyroid gland, quantitative T3 - T4, quantitative insulin by radioactive methods ...

Gastrointestinal: Kotler test, gastroscopy - duodenum, biliary tract, liver, stomach biopsy ...

Kidney - urinary: Photograph of the urinary system with contrast material, upstream kidney scan, kidney biopsy ...

Muscle - bone - joint: Joint scan, measure osteoporosis ...

Neurology: Legal tests, MRI scan, CT scan of the skull, puncture of cerebrospinal fluid, examine the components of cerebrospinal fluid, electroencephalogram….

Implementing the quadrants

Differential diagnosis, cause or form of the disease

Is there such a disease with similar symptoms, there is a lack of tests to clarify them.

Direction of treatment

Treat symptom & cause treatment

Cause treatment: The cause of the disease & the cause of the exacerbation of the patient must be hospitalized.

In the split treatment: attack - maintain - consolidate (in some chronic diseases, do not forget about therapeutic methods)

Prognosis

Proximity: Must gather objective and subjective factors to evaluate (duration of illness, patient condition, condition, applied treatment methods, K / benign/chronic disease, financial event ...)

Far: Good or bad (based on the factors listed above) 

Conclude

What is the main disease or secondary disease??

Postoperative medical record

Due to the characteristics of surgery and to make it easier for students to understand how to examine a patient after surgery - we further specify the method of making a postoperative medical record as follows:

Administration

Asked the disease

Reason for admission: Similar to the preoperative medical record.

Medical history:

In principle, the exploitation of the medical history is the same as the pre-operative medical record, whose purpose is to diagnose and treat postoperative medical records (postoperative diseases or complications, complications of the postoperative period). surgery) so it is most important to exploit the development of the medical condition from postoperative to the time of making a medical record. The history of the postoperative medical record can be divided into the following 3 processes:

Preoperative process:

Only the main functional symptoms and diagnosis before surgery

Surgery process (this section asks the surgeon)

Surgery or emergency surgery.

Date and time of surgery.

Insensitive method

Describe carefully the injury and treatment method

Surgical complications (both by anaesthesia and surgery - if any)

Postoperative process (this is the most important part):

If the patient has just operated in the first 24 to 48 hours (without means), it is necessary to focus on meticulously exploiting the symptoms of complications caused by anaesthesia or surgery.

If the patient has operated for many days, then the exploitation of symptoms of the first 24 - 48 hours does not need to be meticulous, detailed, but only briefly described.

In general, the exploitation of a patient's history after surgery before the time of examination (particularly abdominal surgery) needs to go into the following issues:

How long after surgery is completely awake (clinical means - with relative nature).

The situation of urination: the first time, the next times, the amount (the number of ml/hour), nature… (the first day and the following days).

On what day is it?

What is the situation of eating, sleeping, and defecating?

The situation of wound, bleeding, pain, fever, pus, dressing change.

The situation of the drainage pipes: first day, the following days: what flow? Quantity (ml / hour)? Nature? The day after surgery is withdrawn?

Evolution of patient ideology, medications and surgical intervention in the postoperative process.

In the end, what are the outstanding symptoms of the current condition? (just note functional symptoms).

Prehistoric

Only exploit the history of diseases related to surgical monitoring, treatment and prognosis.

Physical examination

What day after surgery? examination hours?

Body: as a preoperative medical record.

Department: like preoperative medical records.

Note: Examine the incision to see if it is dry and healed, is there any swelling, pain, or discharge of pus? 

Preliminary diagnosis

Like preoperative medical records.

Subclinical

Like preoperative medical records.

Note: Do not mention the preoperative subclinical results. 

Summary of medical records and definitive diagnosis

Male / female patient, age.

Admission: hour, day, month, year.

Reason for admission.

Diagnosis before surgery.

Surgical diagnosis.

Treatment method.

The patient after surgery what day, found:

Identify symptoms (if complete), or main symptoms.

Specific subclinical symptoms

Medical history (if applicable)

Diagnose

After what surgery? how to handle? What day? (After surgery to cut stomach, cancer or tumour, 7th-day duodenal fistula).

What is normal or have complications?

Treatment

Like preoperative medical records.

Prognosis

Like preoperative medical records.

Prevention

Like preoperative medical records.

Day month Year…

Medical records

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