How to write a medical record abstract
Medical record abstracts are an important part of medical records and can help doctors quickly understand a patient's condition and treatment history. This article will introduce in detail the writing method of medical record abstracts, and provide you with a structured data reference based on the hot topics and hot content on the Internet in the past 10 days.
1. Basic structure of medical record abstract
Medical record summaries usually include the following sections:
| part name | Content description |
|---|---|
| Basic patient information | Name, gender, age, occupation, etc. |
| Chief complaint | Main symptoms and duration of patient presentation |
| History of present illness | Detailed description of current disease progression |
| past history | The patient’s past disease history, surgical history, etc. |
| Physical examination | Positive signs found during doctor's examination |
| Auxiliary inspection | Results of laboratory tests, imaging tests, etc. |
| preliminary diagnosis | The doctor's preliminary judgment of the condition |
| Handling opinions | Recommended treatments and precautions |
2. Key points for writing medical record abstracts
1.Accuracy:All content must be true and accurate and may not exaggerate or minimize the condition.
2.Completeness:It is necessary to fully reflect the patient's condition and important information must not be omitted.
3.Organized:Organize content in chronological or logical order for easy reading and comprehension.
4.Professionalism:Use standard medical terminology and avoid colloquial expressions.
3. References to recent hot medical topics
The following are medical and health topics that have been discussed frequently across the Internet recently, and can be used as a reference background for writing medical record abstracts:
| hot topics | Related data |
|---|---|
| Spread of new coronavirus variants | The number of new cases has increased by 15% in the past 10 days |
| High incidence of seasonal flu | Outpatient volume increased by 30% year-on-year |
| Artificial Intelligence Assisted Diagnosis | Accuracy rate reaches 92% |
| Electronic medical record promotion | The coverage rate of tertiary hospitals has reached 85% |
| mental health concerns | Consultation volume increased by 40% year-on-year |
4. Medical record abstract sample template
The following is a standard cardiovascular disease medical record summary template:
| Project | content |
|---|---|
| patient information | Zhang Moumou, male, 58 years old, retired |
| Chief complaint | Recurrent chest tightness and shortness of breath for 2 years, worsening for 1 week |
| History of present illness | 2 years ago, I had chest tightness without obvious triggers, which worsened after activity...1 week ago, the symptoms worsened... |
| past history | 10-year history of hypertension, highest 180/110mmHg |
| Physical examination | BP 150/90mmHg, heart rate 78 beats/min, regular... |
| Auxiliary inspection | Electrocardiogram shows: sinus rhythm, ST-T changes... |
| preliminary diagnosis | 1. Coronary heart disease, unstable angina pectoris 2. Hypertension grade 3, very high risk |
| Handling opinions | It is recommended to be hospitalized and complete coronary angiography examination... |
5. Common mistakes in medical record abstracts
1.Incomplete information:Missing important test results or medical history.
2.Vague expression:Use uncertain words such as "maybe" and "probably".
3.Time confusion:Failure to describe the progression of the disease in chronological order.
4.Terminology error:Use non-technical or incorrect terminology.
6. Summary
Writing standardized medical record summaries requires a combination of clinical experience and expertise. Doctors should pay attention to the quality of medical record abstracts, which are not only related to the quality of patient diagnosis and treatment, but are also an important part of medical and legal documents. As electronic medical records gain popularity, standardized, structured medical record summaries will become increasingly important.
During the writing process, you can refer to the latest clinical guidelines and diagnostic and treatment specifications, and also pay attention to current medical hot spots and epidemiological trends, which will help make more accurate diagnosis and treatment recommendations.
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