"Today, the weather is warm, I went to the ward with Dr. Wang, Dr. Wang asked the patient how he was, the patient said it was much better, Dr. Wang smiled, and the patient smiled..."

As soon as Chen Qi finished reading aloud, the people in the pavilion were out of breath with laughter, and Bian Hongen grabbed Li Sujuan's body, laughing and scolding:

"Su Juan, are you writing an essay for elementary school students? I'm laughing to death, where is the course of the disease recorded? ”

Li Sujuan's face had turned into a red apple, but she still didn't admit it, and muttered in a low voice:

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

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

"You did write it down truthfully, if it is a student essay, it is fine, but as a medical professional document, it is not possible, a formal record of the course of the disease, should include the changes in the patient's condition, important auxiliary examination results and clinical significance.

In addition, there are also opinions of senior physicians on ward rounds, consultations, analysis and discussion opinions of physicians, diagnosis and treatment measures taken and their effects, changes in doctor's orders and reasons, and important matters to be notified to patients and their close relatives. ”

When the classmates heard that Class Leader Chen had started to lecture, they didn't smile, they all lowered their heads and hurried to record the first sentence Chen Qi said, and everyone's expressions were very serious.

"For this record of the course of the disease, you can write like this: the patient was admitted to the hospital for two days, his condition was stable, he still had a low-grade fever of about 38°C, and the joint swelling and pain did not worsen.

This morning, Dr. Wang Moumou made a ward round, listened to the medical history report and physical examination, and believed that according to the patient's presentation of migratory swelling and pain in large joints, subcutaneous nodules, rapid erythrocyte sedimentation rate, and ST-T changes in electrocardiogram, he agreed with the original diagnosis and treatment intentions.

In view of the patient's multiple subcutaneous nodules, 24-hour urine uric acid quantification and joint imaging were ordered to rule out pain. Anti-dampness therapy has been started, and changes in the condition should be closely observed. The above is carried out in accordance with the instructions. ”

Chen Qi added:

"If there is any auxiliary examination report on the same day, the results should also be written into the course of the disease record in time, so that the senior doctor can see the course of the disease and can see the changes in the patient's condition over the past few days at a glance and know in his heart.

At the same time, it is also a piece of evidence, so as not to have a medical dispute in the future, the doctor is not clear, so everyone must record carefully, do not be afraid of trouble, and at the same time the writing must be standardized, and Li Sujuan's mistakes will not be made again. ”

As soon as these words came out, the students in the pavilion also nodded vigorously, and everyone had a feeling that everyone was not facing a classmate, but a teacher.

Chen Qi took Hu Jie's medical record again, and then rolled his eyes:

"This is a consultation list, listen to it, everyone thinks it is right to write it like this: the reason is written on the consultation list: the patient complains, unspeakably uncomfortable."

Hahaha, the gazebo burst into laughter again.

Chen Qi grabbed Hu Jie, "Come on, Doctor Hu, if you are a consulting doctor, if you see such a reason for consultation, will you kill this intern who wrote the application form?" ”

Hu Jie was also a little unable to get off the stage: "This and this, the patient just said that he couldn't say it was uncomfortable." ”

After Chen Qi looked through the entire medical record, his voice raised a few points:

"The consultation form is to be sent to the consulting doctor, so that the consulting doctor needs to see the chief complaint and roughly know what the condition is, which is very important, especially for emergency consultation, it must be concise and concise.

If you are the doctor who sends out the consultation invitation and you can't tell what the patient's situation is, then the other doctor's department will not know where to start, and it is impossible for the other party's department to send a professional doctor to participate in the consultation, and the patient's condition will be delayed.

Therefore, the correct consultation form must be filled in detail with the application for consultation items, briefly focusing on the patient's condition and diagnosis and treatment, the reason and purpose of the consultation, and then signed by the instructor, and then you will send the application form to the inviting consultation department.

It should be noted here that the consultation is generally completed within 48 hours, and mild patients who need special examinations can make an appointment to go to the specialist for examination. Emergency consultation in the hospital must be in place within 10 minutes. ”

Chen Qi flipped through the medical records brought by the 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, and everyone learns to write medical records and medical course records. That's caused by inexperience.

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

In the dean's office on the third floor.

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

Curiously, he stretched out his head to take a look, and saw a group of newly registered health school interns, discussing something in the garden, each holding a medical record in their hands.

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

When he got to the garden, he didn't bother the group of students, but stood in a corner, just in time to hear the interns talking.

Dr. Guo was surprised to find that the interns were discussing the issue of standardizing the writing of medical records.

What surprised him even more was that there was no teacher teaching on the spot, but the intern who pointed out the basilar skull 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:

is the same intern, the same class, the same age group, how can there be such a big gap? This kid doesn't look like a student, but he is clearly a veteran doctor with a lot of clinical experience.

At the same time, Dean Guo thought of the topic of diagnosing basilar skull fracture yesterday, and strengthened his idea that when the internship was over, he must bring this kid to the People's Hospital.

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

At this time, Dr. Li Jun from the Department of Foreign Affairs was passing by the garden with Zhang Jun and Ai Kelong, and after hearing the laughter, he glanced at it casually, and saw the intern doctor who couldn't get off the stage yesterday, and his brows furrowed.

Zhang Jun was very good at looking at his face, so he walked over slowly:

"Yo, the students study very hard, and they are still discussing problems without a break at noon, what are you discussing? Oh, medical record writing? Oh my God, you don't know how to write such a simple medical record, do you? Is the quality of teaching in your school so poor? ”

As soon as these words came out, they immediately aroused public outrage!