The key doctor claims to write the case history of book from heaven is forced The electronic case history is a future direction

The key doctor claims to write the case history of book from heaven is forced The electronic case history is a future direction
Today newspaper reporter Wu intern favor / reporter Xiang Shens gentles east Li /last " last norms basic case history " that Ministry of Public Health issue, carry out in each hospital of our province from March 1. According to the regulation, the case history writes and uses the medical terminology in conformity with the norm, the characters are careful and neat, it is accurate to state. The reporter investigates 6 province and cities, district hospitals secretly recently, find " book from heaven " The case history is obviously reduced, but the doctor signs the lively and vigorous situation is still very common. The insider claims, the electronic case history should be the future developing direction. Young doctor write case history, relatively before the one month such as norm, Zhengzhou citizen Ms. tripped in the snowfield in week. " I had the first film blue and green silt on the leg at that time, but the doctor said the bone had little trouble " . Think week lady have on the heart on bottom,but word in case history except date and the names of she, any of her can not understand. " the case history writes the basic norm " that Ministry of Public Health issues begins to carry out on March 1, on March 8, when she goes to reexamine and change dressings, that doctor, but the writing on the case history has been already obviously clear. In the interview, the reporter notices a phenomenon, the young doctor is while writing the case history, mostly slower, the characters are careful and neat, the speed that and the key doctor writes the case history is mostly faster, the writing is relatively hasty and careless too. " book from heaven " The case history still exist " faints, is this what is written? " In managing a hospital of urban area, have studied bringing to the son 7 months old the high lady who saw the doctor for half a day without understanding the case history. "I to graduate from university too, but you watch case history this, symptom, and what is medicine that turn on, can't understand completely. The doctor signs like a flower too, ' overbearing grass ' more yet than the star. " The high lady says angrily. "When I am just in hospital, can not understand the prescription that a doctor prescribed either. " A physician whose surname is Liu says, after working for half a year, she distinguishes the script with more than ten doctors with one's own work relationship. But if meet the patient transferring from one hospital to another, once the writing of the original case history is hasty and careless, relatively have a headache. Reporter compare 6 20 case history of hospital with, find less than 5ing very clear to recognize, 10 parts are all a little hasty and careless, but see carefully that still can admit. There are 5 case histories, 70%-80% of the words can not be all recognized. The doctor claims the patient is forced more to be hasty and careless to " sometimes has no way. " An oculist handling reporter's disease says, will " see more than 20 patients in an hour when being the busiest, how much time is there the woolen cloth in writing of flower? " In clinic of ophthalmology department, reporters have observed two and written the clear and normal doctor, they finish writing a case history, costs about 5 minutes, in addition, diagnose and check time, the flower has 10 minutes at least on a patient, will come down in an hour and see 6 patients at most, " can't wait to rank the following patient according to such a speed " . If, the expert of the large hospital writes hasty and carelessly because there are too many patients, those some doctors of hospitals at the basic level, when there are few patients, why write hasty and carelessly too? The respiratory medicine grandson of a district hospital in Zhengzhou is surnamed that the doctor says, estimate that is afraid the patient " runs in the side " . "Medicine in the dispensary is cheaper than that of the hospital, and can brush the medical insurance card too. " Doctor Sun reveals, some small hospitals set up the code word on case history and prescription on purpose, only the person in the dispensary of their hospital can understand. An internal medicine department expert saving the People's Hospital in the direction says that the electronic case history is the future, let one doctor one who is used to writing the quick word write the case history drawing, need time to suit. At present, the doctors of most hospitals are handwritten case histories. According to the introduction of this expert, the electronic case history form which province the People's Hospital adopts, it is a good method. Although the case history of the clinic is handwritten, when the patient get it filled, the electronic case history has been printed out. The expert say, popularize electronic case history can let " the the intersection of book from heaven and case history " Elimination. As to paper case history, the electronic case history is " written " It is easy to stand up, and the storing amount is great, information is intact, it is more convenient to read, the patient can be very clear too to medicine used, " the electronic case history is the future developing direction " .

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