摘要
目的讨论急性一氧化碳中毒病历特点。方法分析我院2008年-2009年急性一氧化碳中毒110份病案,在此基础上分析急性一氧化碳中毒病案书写在各个环节上应突出的重点和应注意的问题。结果一氧化碳中毒病案书写在病史、体格检查、鉴别诊断和诊疗计划方面均有别于其他疾病的特点。结论一氧化碳中毒病历书写应体现临床医师的专业素养,其病案在流行病学调查、科研、医学证据等方面有重要作用。
Objective to discuss the characteristic of acute carbon monoxide poisoning （ACOP） medical records writing. Methods an analysis on 110 medical records of ACOP from 2008 to 2009 in our hospital. At the basis of that to analyze the key point and problems of ACOP medical records writing. Results it is believed that ACOP patients have their specialty. We should pay attention to the characteristic of medical history, the medical examination, the diagnosis and differential diagnoses and treatment plan. Conclusion Medical record writing should manifest clinician＇s professional accomplishment. It plays an important role in aspects of epidemiology investigation, scientific research and medicine evidence.
出处
《中国病案》
2010年第11期18-20,共3页
Chinese Medical Record
关键词
一氧化碳
中毒
病案
carbon monoxide
poisoning
medical records
