What is a medical course record, and how many days is it written?

The course of illness record refers to the continuous record of the patient's condition and diagnosis and treatment process after the hospitalization record. The contents include the changes in the patient's condition, the results of important auxiliary examinations and their clinical significance, the opinions of senior physicians on ward rounds, consultation opinions, physicians' analysis and discussion opinions, the diagnosis and treatment measures taken and their effects, the changes and reasons for doctor's orders, and important matters to be informed to patients and their close relatives.

1) The first course of illness record refers to the record of the first course of illness written by the treating physician or the physician on duty after the patient is admitted to the hospital, which shall be completed within 8 hours of the patient's admission. The content of the first course of the disease record includes the characteristics of the case, the discussion of the proposed diagnosis (diagnosis basis and differential diagnosis), and the diagnosis and treatment plan.

1.Characteristics of the case: The characteristics of the case should be written after a comprehensive analysis, induction and collation of the medical history, physical examination and auxiliary examinations, including positive findings and negative symptoms and signs with differential diagnostic significance.

2.Probable diagnosis discussion (diagnosis basis and differential diagnosis): According to the characteristics of the case, the preliminary diagnosis and diagnosis basis are proposed; Write out and analyze the differential diagnosis of unclear diagnosis; The next diagnosis and treatment measures were analyzed.

3.Diagnosis and treatment plan: put forward specific examination and measure arrangement.

Article 22 of the Basic Standards for Writing Medical Records 2010 stipulates that "the record of the course of illness refers to the continuous record of the patient's condition and diagnosis and treatment process after the admission record." The contents include the changes in the patient's condition, the results of important auxiliary examinations and their clinical significance, the opinions of senior physicians on ward rounds, consultation opinions, physicians' analysis and discussion opinions, the diagnosis and treatment measures taken and their effects, the changes and reasons for doctor's orders, and important matters to be informed to patients and their close relatives. ”

Disease course records: records of the diagnosis,**, changes in condition, ancillary examination results, and continuity of clinical significance during hospitalization.

According to the case writing specifications, the time of disease recording is different, as follows:

1. For critically ill patients, write a record of the course of the disease at any time according to the change of their condition, at least once a day if there is no change, and the recording time should be specific to the minute.

2. For seriously ill patients, record the course of the disease at least once every 2 days.

3. For patients with stable conditions, record the course of the disease at least once every 3 days.

2 days.

The basic principles of medical record writing: medical record writing should be objective, truthful, accurate, timely and complete. Timely is a problem that many medical staff are easy to ignore when filling in, and if the content of the medical record is not filled in in time, it is easy to cause the omission or error of patient information, affect the quality of the medical record, and even cause legal disputes.

Requirements and contents of disease course records:

The first course record refers to the first course record written by the treating physician or the physician on duty after the patient is admitted to the hospital, and should be completed within 8 hours of the patient's admissionThe content of the first course of the disease record includes the characteristics of the case, the discussion of the proposed diagnosis (diagnosis basis and differential diagnosis), and the diagnosis and treatment plan.

Characteristics of the case: The characteristics of the case should be written after a comprehensive analysis, induction and collation of the medical history, physical examination and auxiliary examinations, including positive findings and negative symptoms and signs with differential diagnostic significance.

Hello dear, there are several ways to view previous medical records:1Go to the hospital:

Bring your ID card, medical card and other documents to the hospital where you are treated, and check it in the ** place or medical archives. 2.Through the hospital's official website:

Some internet medical platforms can query the medical records of your medical treatment on the platform. 4.Through the health file slippery letter lead case:

If you have already established a personal health record in your local health profile system, you can log in to your health profile** or check it through the mobile app. Either way, you'll need to bring your documents and information about your visit, such as the time of your visit, the name of your doctor, etc. At the same time, the inquiry method of different hospitals may be different, and you need to operate according to the regulations of the specific hospital, I hope the above will be helpful to you

Summary. Hello, dear is happy to answer for you: how to check previous medical records:

You can check through Alipay. 1.First of all, open the homepage of the Alipay app, enter the hospital you are treating in the search bar, and click on the hospital in the search results"My report"Enter Mini Program 2, enter the hospital Mini Program page, enter the authentication information, and click Confirm.

3. After the certification is passed, you can see my electronic case report.

Hello, I am happy to answer for you: How to check previous medical records: You can check through Alipay.

1.First of all, open the homepage of the Alipay app, enter the hospital you are treating in the search bar, and click on the hospital in the search results"My report"Enter Mini Program 2, enter the hospital Mini Program page, enter the authentication information, and click Confirm. 3. After the certification is passed, you can see my electronic case report.

In addition, you can take your ID card to the hospital record room to check and make copies. If you have been discharged from the hospital for several years, it is recommended to contact the hospital before going, because many hospitals will file files that are not used for many years and will be archived to other addresses. If it is inconvenient to travel to and from the hospital, you can generally entrust someone else to handle it.

You can also log in to the personal medical record inquiry website. First of all, log in to the official hospital ** click on the personal medical record query, submit the inquiry application and wait for approval and approval. The system can query and display relevant information according to the patient's number, the ward number, and the attending doctor's work number.

And can retain a large number of patient medical record information, file information, laboratory data, and other systems, according to the patient's number, ward number, and the attending doctor's work number for query, respectively, to display relevant information. And it can retain a large number of patient medical record information, file information, laboratory data, etc.