文档库

最新最全的文档下载
当前位置:文档库 > 英文病历书写要求

英文病历书写要求

原文来自:湘雅医学翻译网

MEDICAL RECORD DOCUMENTATION

Incomplete inpatient medical record documentation will be identified by UTMB staff. Y ou 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,

英文病历书写要求

(共3页)