"It's a warm day today. I went with Dr. Wang for ward rounds. Dr. Wang asked how the patient was doing. The patient said he was much better. Dr. Wang smiled, and so did the patient..."

As soon as Chen Qi finished reading, everyone in the pavilion was laughing so hard that they were out of breath. Bian Hongen leaned on Li Sujuan, laughing and cursing:

"Sujuan, are you writing a composition for primary school students? You're laughing so hard at me. Where is the disease history record here?"

Li Sujuan's face turned into a red apple, but she still refused to admit it and murmured in a low voice:

"I just faithfully wrote down the scene of the ward rounds at that time. I didn't make it up at all."

Chen Qi laughed for a long time and cleared his throat:

"You have indeed written it down truthfully. If it is a student composition, it is fine, but as a medical professional document, it is not acceptable. A formal disease course record should include the patient's condition changes, important auxiliary examination results and clinical significance.

In addition, there are superior doctors’ ward rounds opinions, consultation opinions, doctors’ analysis and discussion opinions, diagnostic and treatment measures taken and their effects, changes in medical orders and reasons, important matters notified to patients and their close relatives, etc.”

When the classmates heard that monitor Chen had begun to lecture, they stopped laughing. They all lowered their heads and took the time to record the first words Chen Qi said. Everyone's expression was very serious.

"For this disease course record, you can write like this: The patient has been hospitalized for two days and his condition is stable. He still has a low fever of about 38°C and the joint swelling and pain have not worsened.

This morning, Dr. Wang made a ward round. After listening to the medical history report and physical examination, he believed that the symptoms of the disease were traveling swelling and pain of the joints, subcutaneous nodules, rapid deposition, and ST-T changes in the electrogram.

, agree with the original diagnosis and treatment intention?.

In view of the multiple subcutaneous nodules in the disease, we ordered 24-hour urine uric acid quantification and joint photography to rule out pain. We have started anti-humidity treatment, and we must closely observe changes in the condition. Follow the above instructions."

Chen Qi added:

"If any auxiliary examination report comes out that day, the results should be written into the disease course record in time. This way, when the superior doctor sees this disease course, he can clearly understand the changes in the patient's condition over the past few days and have a clear idea.

At the same time, it is also a piece of evidence, so that if there is a medical dispute in the future, the doctor will not be able to explain it clearly, so everyone must record it carefully and don’t be afraid of trouble. At the same time, the writing must be standardized, so that Li Sujuan’s mistakes will not be made again.”

As soon as these words came out, the students in the pavilion nodded their heads one after another. Everyone had a feeling that they were not facing a classmate, but a teacher.

Chen Qi took Hu Jie's medical records and rolled his eyes:

"This is a consultation form. Listen, do you think it is right to write it this way? The reason is written on the consultation form: The patient complained of unspeakable discomfort."

Hahaha, the pavilion burst into laughter again.

Chen Qi grabbed Hu Jie and said, "Come on, Doctor Hu, if you were a consulting doctor and saw such a reason for consultation, would you kill the intern who wrote the application form?"

Hu Jie was also a little embarrassed: "Well, the patient at that time just said that he was unspeakably uncomfortable."

After Chen Qi looked through the entire medical record, his tone rose a bit:

"The consultation order must be sent to the consulting doctor, so the consulting doctor needs to know the main complaint and roughly know what the condition is. This is very important, especially for emergency consultations, it must be concise and concise.

As the doctor who issued the invitation for consultation, you can't tell the patient's condition clearly, so the other doctor has no way to start, and it is impossible for the other department to send professional doctors to participate in the consultation. What will be delayed is the patient's condition.

Therefore, for a correct consultation form, you must fill in the consultation application items of the application form in detail, briefly focus on describing the patient's condition and diagnosis and treatment, and the reasons and reasons for applying for consultation. After writing, give it to the teacher to sign, and then submit the application form

Send an invitation to the consultation department.

It should be noted here that general consultations are completed within 48 hours. For minor illnesses that require special examinations, you can make an appointment to go to a specialist for examination. Emergency consultations in the hospital must be in place within 10 minutes."

Chen Qi turned over the medical records brought by his classmates one by one and pointed out the problems one by one.

The effect of this kind of practical exercise is far better than the theoretical teaching in the classroom. Everyone has learned how to write medical records and medical records, but why are there still so many mistakes after getting started? This is caused by lack of experience.

Chen Qi has been an intern dog for many years, and he also personally teaches students while working, so it is a piece of cake for him to teach interns relevant knowledge points.

In the dean’s office on the third floor.

After having lunch, Dean Guo Yuanhang was about to close the curtains and rest for a while, when he suddenly heard bursts of laughter coming from the garden downstairs.

He stretched out his head curiously and saw a group of medical school interns who had just registered, discussing something heatedly in the garden, each holding a medical record folder in their hand.

Dean Guo felt a little curious. Anyway, he had just finished lunch and he wanted to take a walk after the meal to help digestion, so he picked up his coat and walked downstairs.

When he arrived in the garden, he did not disturb the group of students. Instead, he stood in a corner and could just hear the conversation of the intern doctors.

Dean Guo was surprised to find that these intern doctors were discussing the issue of standardized writing of medical records.

What surprised him even more was that there was no teacher teaching at the scene. Instead, the intern who pointed out the skull base fracture yesterday was helping the students point out the mistakes and shortcomings one by one.

Dean Guo couldn't help but look at Chen Qi a few more times and thought:

They are both intern doctors, from the same class, in the same age group, how come there is such a big gap? This guy doesn’t even look like a student, he is clearly a senior doctor with rich clinical experience.

At the same time, Director Guo thought about yesterday's skull base fracture diagnosis project again, and strengthened his mind. When the internship is over, he must bring this kid to the People's Hospital.

Chen Qi didn't know that he was "Jane in the Emperor's Heart", but he was still teaching his classmates how to correctly write down medical records and related documents.

At this time, Dr. Li Jun from the First Department of Surgery was taking Zhang Jun and Ai Kelong as they passed by the garden. After hearing laughter, they took a casual look and saw the intern doctor who made him unable to come to the stage yesterday, frowning.

It wrinkled up.

Zhang Jun was very good at reading faces, so he walked over slowly:

"Hey, students are studying very hard. They are still discussing problems without taking a break at noon. What are you discussing? Oh, writing medical records? My God, you can't even write such a simple medical record, right? What's the quality of teaching in your health school?

Is it so bad?"
Chapter completed!