Key points of recheck medical records of Zhongshan Ophthalmology Department
Zhongshan Ophthalmology Hospital is a well-known ophthalmic hospital in Guangzhou, providing professional ophthalmic examination and treatment services. For patients, reviewing medical records is an important tool to evaluate the development of the disease and guide treatment. The following will elaborate on the key points that need to be paid attention to when reviewing the medical records in Zhongshan Ophthalmology Department from four aspects: medical history, signs, auxiliary examinations and treatment plans.
1. Medical history
When reviewing the medical records, paying attention to the medical history is an important step to understand the development of the disease. First, we need to pay attention to the change of symptoms. Whether the patient feels the improvement or deterioration of eye discomfort, pain or vision loss. Next, ask if there is a new disease or diagnosis. For example, whether there are new problems such as eye infection or inflammation. In addition, ask about the patient's medical treatment and treatment, including whether to use the medicine and carry out necessary treatment according to the doctor's advice.
Further, it is necessary to review the past medical history. Pay attention to whether the patient has chronic diseases related to eye health, such as hypertension, diabetes, glaucoma, etc. It is very helpful to understand the past history of surgery, drug allergy, and whether there are ophthalmic diseases in the family for assessing the development of the disease.
2. Physical signs
It is very important to evaluate the patient's eye signs when reviewing the medical records. First, you need to check the size and shape of the pupil. The normal pupil diameter is about 3-4 mm. If there are abnormalities such as dilated or dilated pupils, it may indicate the existence of eye diseases. In addition, pay attention to the transparency and color of the cornea, and check whether there are conjunctival congestion and exophthalmos.
Furthermore, the examination of intraocular pressure is an important indicator to evaluate the condition of glaucoma. The intraocular pressure can be measured to determine whether the intraocular pressure is normal, and high intraocular pressure may mean the development of glaucoma. In addition, the examination of the pupillary response to light, fundus, eyelid, lacrimal gland and other aspects can also provide important information about the development of the disease.
3. Auxiliary inspection
In the reexamination of medical records, the results of auxiliary examinations are an important basis for understanding the changes in the condition. Among them, vision examination is one of the basic auxiliary examinations. The recovery or decline of vision can be understood by measuring the naked vision and corrected vision of patients. Fundus photography and OCT examination can provide detailed information of fundus diseases, such as macular degeneration, retinal detachment, etc. In addition, corneal topography, electrooculogram and visual field examination are also common auxiliary examinations for evaluating the development of ocular disease.
According to the specific condition, doctors can also carry out special examinations as needed, such as eyelid biological examination, eye CT or MRI, to further understand the eye conditions.
4. Treatment plan
*Later, when reviewing the medical records, it is very important to pay attention to the treatment plan formulated by the doctor. The doctor may adjust or continue the previous treatment plan according to the recheck results and the patient's condition changes. At the same time, doctors may also decide whether to take other treatment methods, such as surgery or drug adjustment, according to the new examination results. It is very important to record the doctor's treatment suggestions and the patient's cooperation in the recheck medical record for evaluating the treatment effect and formulating the follow-up treatment plan.
Summary
To sum up, the focus of Zhongshan's ophthalmic recheck medical records mainly includes four aspects: medical history, signs, auxiliary examinations and treatment plans. The knowledge of the medical history can help doctors to assess the changes in the condition and guide treatment. Examination of signs provides an objective assessment of eye condition. The auxiliary examination results provide more detailed information about eye lesions. The treatment plan formulated by doctors reflects the adjustment of treatment strategies and the guidance of disease development. By comprehensively focusing on these key points, reviewing the medical record can better assess the development of the disease and guide the follow-up treatment plan.
