试论病历书写的四个阶段

Discussion about the Four Stages of Medical Record Writing

从认识论角度看,住院过程是一个完整的认识过程,对病情的认识随着时间的递进在不断深化。正确临床思维的要点之一是后一阶段应对前一阶段建立的诊断不断进行验证,可以据此把住院病历书写过程划分为四个阶段。不同阶段有不同的反映载体,不同阶段应使用不同的诊断称谓。这些不同的载体和不同的诊断称谓体现着不同的认识深度和广度,也是反映病历内涵质量的重要方面。首次病程记录的功能定位应当是能够反映入院时最主要的病情即可,其栏目设置应高度简练,并应排列在入院记录之前。确诊任务通常在第三阶段才完成,建议在内科病历中书写一个"第三阶段小结"。

The process of hospitalization is a complete cognitive process from the perspective of epistemology and the understanding of the condition is continuously deepened with the progress of time.One of the key points of the correct clinical thinking is that the diagnosis was established in the previous stage should be verified by latter stages.According to the idea,the process of medical record writing can be divided into four stages.There are different carriers in the different stages and various diagnostic appellations should be used in the different stages.These different carriers and different diagnosis appellation reflects different understanding depth and width,also those different things are one of the important aspects of the quality of connotation in the medical record.The primary function of the first record of disease process is just to reflecting the most important condition;its content should be highly concise and be arranged at the front of the admission record.Usually,the task of confirming diagnosis is completed in the third stage.Therefore,it is suggested that ＂the summary of third stage＂ be written in the medical record.