论文部分内容阅读
首诊门诊病案的内容 ,是门诊病案的核心部分。写好首诊门诊内容 ,既是患者就诊所必需的 ,又是保护患者和医疗机构及其医务人员合法权益的重要方面。为此 ,要高度重视首诊门诊病案的书写 ,并作为医院目标管理标准的重要项目之一。面对首诊对象的复杂性及诊治过程的短暂性和不连
The contents of the first outpatient medical record is the core part of the outpatient medical record. Writing out the contents of the first outpatient clinic is both necessary for the patient clinic and an important aspect of protecting the legitimate rights and interests of patients and medical institutions and their medical staff. To this end, we must attach great importance to the writing of first outpatient medical records and serve as one of the important items in the hospital’s goal management standards. Faced with the complexity of the first visit and the transient and non-continuous diagnosis and treatment process