埃博拉病毒病患者病历书写和管理的探讨

Investigation on the Medical Records Writing and Management of Patients with Ebola Virus Disease

某院抽组的医疗队在赴非收治埃博拉病毒病烈性传染病患者时,面对病史采集、病历书写、病历传输等方面的新情况,医疗队对当地配属医务人员进行了病史采集和病历书写培训,制定了入院首次记录和日常查房病程记录的表格式病历模板,规范了病历书写内容和形式,并利用当地现有条件实现了病历从隔离区到清洁区的有效传输,对后期临床病例的统计分析和临床科研提供了基础素材,以上问题的逐步解决为今后国内外收治烈性传染病患者时如何进一步做好病历书写和管理积累了一定经验。

Confront of the new situations such as medical history collection, medical records writing and transfer, the medical staff who were selected from a hospital to treat the patients with fulmination infectious disease caused by the Ebola virus in Africa had conducted training on the local medical workers on medical history collection and medical records writing, formulated the table form medical records template of the first records as well as daily ward round record, standardized the form and writing content, and also realized effective transfer of medical records from isolation area to clean area by the local condition, which provided basic materials for the statistical analysis and clinical research for the later clinical cases. The gradually solution of above questions could accumulate experience for how to do well in the writing and management of medical records in the treatment of patients with fulmination infectious disease in the future.