How to write the doctor patient communication record, and how long after the doctor patient communic

1) Name of the first bedside doctor-patient communication record: Hospitalization number: 1. Preliminary diagnosis:

2. Diagnosis basis: 3. Disease status and disease course stage: 4. Preliminary ** plan (drug**, surgery**, radiotherapy and chemotherapy):

8. Matters requiring the cooperation of patients and their families9. Other situations that patients need to know: Today, the patient (or family members) communicated with the patient (or family members) about the above situation and gave a detailed explanation, and the patients (family members) have fully understood and agreed. Signature of the patient (or his/her **person):

Signature of the physician participating in the communication: year, month and day (2) Name of the doctor-patient communication record sheet during hospitalization Hospitalization number 1, clear diagnosis: 2, main means:

3. Important examinations and results: 4. Possible complications: 5. Drug use and its adverse reactions

Today, we communicated with the patient (or family member) about the above situation and gave a detailed explanation, and the patient (family member) has fully understood and agreed. Signature of the patient (or his/her **person): Signature of the physician participating in the communication:

Note: The doctor-patient communication record sheet during hospitalization is required for non-surgical departments, and the operating department can replace it with preoperative conversation records. (3) The name of the postoperative doctor-patient communication record Hospitalization number 1, the general course of the operation, whether it went smoothly, and whether it is consistent with the preoperative diagnosis

2. Postoperative diagnosis: 3. Postoperative main**: 4. Postoperative precautions:

5. Matters requiring the patient's cooperation: Today, the patient (or family member) has communicated with the patient (or family member) about the above situation and explained in detail, and the patient (family member) has fully understood and agreed. Signature of the patient (or his/her **person):

Signature of the physician participating in the communication: year, month and day (4) Name of the doctor-patient communication record before discharge Hospitalization number 1, Brief **Process: 2, Pre-discharge diagnosis:

3. **Effect: 4. Precautions after discharge: 5. Discharge medication and usage:

6. Follow-up: Today, we communicated with the patient (or family member) about the above situation and gave a detailed explanation, and the patient (family member) has fully understood and agreed. Signature of the patient (or his/her **person):

Signature of the physician participating in the communication: YYYYYYYYYYYYYYYYYYYYYYYY

Is it included in the medical record or is it an internal hospital information?

After the patient is admitted to the hospital, the attending physician should communicate with the patient or family in a timely manner, and the communication should be completed within 48 hours at the latest. Writing of Doctor-Patient Communication Records "Medical Record Writing Specifications" Article 10 For medical activities that require the written consent of the patient, the patient shall sign the consent form. The doctor-patient communication record described above should be signed by the doctor as soon as the communication is completed.

(1) Record of the first bedside doctor-patient communication.

Name: Hospitalization Number:

Initial diagnosis: Basis of diagnosis:

Condition and stage of the disease:

Preliminary ** regimen (drug**, surgery**, chemoradiotherapy):

Further** and inspection protocol:

**Risks, Medications*** & Cost Estimates:

Matters that require the cooperation of patients and their families.

Other things the patient needs to know:

Today with patients.

or family members) have communicated with each other and explained in detail, and the patient (family member) has fully understood and agreed.

Signature of the patient (or his/her **person):

Signature of the physician participating in the communication: years. Month.

Day. (2) Doctor-patient communication records during hospitalization.

Name. Hospitalization number.

Definitive diagnosis: the main **means:

Important Tests and Results:

Possible complications:

Drug use and its adverse effects:

Today with patients.

or family members) have communicated with each other and explained in detail, and the patient (family member) has fully understood and agreed.

Signature of the patient (or his/her **person):

Signature of the physician participating in the communication: years. Month.

Day. Note: The doctor-patient communication record during hospitalization is required for non-surgical departments, and the operating department can replace it with preoperative conversation records.

3) Postoperative doctor-patient communication records.

Name. Hospitalization number.

The general course of the operation, whether it went smoothly, and whether it is consistent with the preoperative diagnosis:

Postoperative diagnosis: postoperative main**:

Postoperative Notes:

Matters requiring the patient's cooperation:

Today with patients.

or family members) have communicated with each other and explained in detail, and the patient (family member) has fully understood and agreed.

Signature of the patient (or his/her **person):

Signature of the physician participating in the communication: years. Month.

Day. (4) Doctor-patient communication records before discharge.

Name. Hospitalization number.

Brief **Process:

Pre-discharge diagnosis:

**Effect: Precautions after discharge:

Discharge medication and usage:

Follow-up: Today with the patient.

or family members) have communicated with each other and explained in detail, and the patient (family member) has fully understood and agreed.

Signature of the patient (or his/her **person):

Signature of the physician participating in the communication: years. Month. Day.