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如何写好英文病历MEDICAL RECORD DOCUMENTATIONIncomplete inpatient medical record documentation will be identified by UTMB staff.You will receive written notification of your incomplete record documentation on a weekly basis through U.S. Postal Service mail.UTMB Bylaws and Rules & Regulations of the Medical Staff state that “no record shall remain incomplete, including signatures, greater than thirty (30) calendar days from discharge”. Final Discharge Note (Form 5346) The Final Discharge Note should be completed at the time of discharge.It should be signed (full signature) and dated by the attending physician.Abbreviations should not be used on this form.The following must be recorded on the form: Principal Diagnosis:The condition which, after study, caused admission to the hospital. Complications (if present):Conditions which developed after admission that may have extended the length of stay and required use of additional resources. Comorbidities (if existing):Conditions present prior to admission that could extend the length of stay or require additional resources. Principal Procedure:The definite/therapeutic procedure most closely related to the principal diagnosis. The discharge plan must be documented, and the availability of appropriate services to meet the patient’s needs after hospitalization must be addressed. History and Physical Examination (Form 2005) A complete history and physical examination shall, in all cases, be written and placed in the record within twenty-four (24) hours after admission of the patient.If a complete history and physical has been obtained within thirty (30) days prior to admission in a physician’s office, a durable legible copy of this report may be used in the patient’s hospital medical record, provided there have been no subsequent changes or if there were changes, the changes have been recorded at the time of admission.A durable, legible original or reproduction of the office or clinical prenatal record is acceptable. The history and physical examination includes at a minimum the patient’s chief complaint, present illness/injury, review of systems, past history, family history and physical examination.The patient’s biophysical, psychosocial, cultural, spiritual, developmental, educational, functional, nutritional, and pain/comfort needs will be addressed as appropriate.The physician H&P will be filed in the H&P section of the medical record. The attending physician must sign and date the History and Physical Examination. Inpatient Progress Note (Form 5300) Inpatient progress notes shall be written to provide a chronological record of the patient’s progress. Notes should be timely, legible, relevant, and sufficiently detailed to permit and justify continuity of care.Progress notes on procedures/operations should also include doctor number after the signature.All notes must be timed, dated and signed.A progress note should be written by a physician everyday and more often on critical patients. Operative Report An operative note must be written and dictated immediately after surgery and should include the items listed below.The report is signed by the appropriate physician(s). 1.preoperative diagnosis; 2.postoperative diagnosis; 3.name of procedure; 4.description of findings; 5.technical procedure used; 6.specimens removed; 7.name of primary surgeon and any assistants; and 8.condition of patient after surgery. Discharge Summary A discharge summary is required on patients discharged from the hospital and should be completed at the time of discharge. The Discharge Summary must contain: 1.name, UH#, date of admission, date of discharge, and attending physician; 2.chief complaint or reason(s) for admission; 3.significant history and physical findings; 4.pertinent laboratory and x-ray findings; 5.treatment rendered; 6.principal and additional or associated diagnoses (indicate principal); 7.surgical procedures; and 8.disposition – include specific instructions given to the patient and/or family, as pertinent (including instructions relating to physical activity, medication, diet, and follow-up care); 9.prognosis. The physician is required to sign and date the discharge summary. Dictated/typed discharge summaries are not required in the following situations: 1.normal obstetric deliveries, including uncomplicated cesarean sections; 2.normal newborns. |
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