Guangzhou Zhongshan Ophthalmology Department: Matters needing attention in rechecking medical records
In the process of medical treatment, re examination of medical records is a very important part. It records the changes of patients' conditions and treatment effects, which has important reference value for doctors. However, in order to ensure the accuracy and completeness of the rechecked medical records, we need to pay attention to the following aspects.
1. Check your personal information carefully
When reviewing the medical record, first of all, the patient's personal information should be carefully checked, including name, age, gender, contact information, etc. These information are very important for doctors. They can help doctors identify patients and understand their special conditions, so as to make more accurate diagnosis and treatment plans.
At the same time, the accuracy of patients' personal information is also an important part of protecting patients' privacy. In the process of checking personal information, it is necessary to ensure the confidentiality of information and prevent information from being disclosed or used by others.
2. Pay attention to the condition description and progress record
In the process of reviewing the medical records, special attention should be paid to the description of the condition and the record of the progress. Doctors should be objective and accurate when recording the condition, and try to avoid the use of subjective assumptions or vague concepts. The description of the condition should include the specific description of symptoms, duration, frequency, etc., and be analyzed in combination with physical signs and examination results.
When recording the progress of the disease, the treatment plan and drug use of the patient should be noted, especially the name, dosage and usage of the drug. This is very important for doctors to evaluate the treatment effect and adjust the treatment plan.
In addition, it is also necessary to note the patient's condition change and treatment effect, especially for new symptoms or side effects, which need to be recorded in time and compared with the previous medical records.
3. Confirm the implementation of medical orders
When reviewing medical records, it is necessary to confirm whether the previous medical orders have been accurately executed. Medical advice refers to the treatment advice and medication guidance issued by doctors for patients. Patients need to carry out corresponding treatment and medication according to the requirements of medical advice, and doctors need to evaluate patients' compliance behavior and treatment effect.
Confirming the implementation of medical orders can help doctors understand patients' cooperation with treatment and compliance with medication, find and correct patients' misconduct or misuse of drugs in a timely manner, and adjust the treatment plan to improve the treatment effect.
4. Comparison of inspection results
In addition to the condition records and the implementation of medical orders, the review of medical records also needs to pay special attention to the examination results of patients. This includes laboratory examination, imaging examination, physiological function test and other examination results.
When reviewing the medical records, it is necessary to analyze the changes and trends against the previous inspection results. Special attention should be paid to the discovery and treatment of abnormal results, such as abnormal blood indicators, abnormal imaging manifestations, etc. These abnormal results are often related to the patient's condition and treatment effect, and need to be evaluated and adjusted in time.
Summary
Reviewing medical records is an important means for doctors to understand the disease development and treatment effect of patients. In the process of reviewing medical records, we need to pay attention to checking personal information, accurately expressing the condition and recording the progress, confirming the implementation of medical orders and comparing the inspection results. These precautions can help doctors fully understand the patient's condition and treatment, make more accurate diagnosis and treatment plans, and improve the treatment effect and satisfaction of patients.
