National expert consensus on medical history collection in wound repair department (2021 version)

doi:10.3877/cma.j.issn.1673-9450.2021.06.001

Abstract

Abstract:

Medical history collection usually refers to the process of obtaining clinical data from systematic inquiry carried out by clinicians, combined with physical, laboratory and equipment examinations to complete the admission records and outpatient medical records. At present, there are many problems in medical records, such as incomplete and non-standard records of medical records, untimely collection of medical records, lack of pictures and data of low quality, and failure to meet international standards. In order to improve the standard level of history collection in wound repair department, based on the current collection of medical records in China and combined with domestic and foreign reports, the expert group elaborates from the aspects of tabular collection of medical history information and wound shooting, to explore how to improve the clinician′s work efficiency and medical record quality, and reduce medical hidden trouble in the process of medical history collection and patient participation mode.

Key words: Burns, Wounds and injurise, Medical history taking, Benchmarking, Wound repair department

Chinese Burn Aossication. National expert consensus on medical history collection in wound repair department (2021 version)[J]. Chinese Journal of Injury Repair and Wound Healing(Electronic Edition), 2021, 16(06): 461-465.

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References 9

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Part A：病史采集主观内容
入院日期____________________记录日期____________________
姓名__________年龄__________职业____________________现住址__________________________单位____________________
性别：□男 □女婚姻：□已婚 □未婚 □离异供史者：□本人 □家属 □其他
【主诉】应在病历管理系统中简明扼要(20字以内)、专业规范地表述创面症状、阳性体征及症状持续时间。创面症状代表：局部情况如红肿热痛、渗出等，阳性体征代表：全身情况如发热等。
【现病史】应按时间顺序记录创面的发生、演变、诊疗等方面情况。具体包括一般情况、创面形成的时间、原因、发展变化情况、有无新症状出现、诊疗经过及效果。一般情况即目前精神、饮食、睡眠、大小便、体重及活动能力等情况。
【既往史】健康状况：□良好　□一般　□较差
	过敏史：□无　□有，过敏原：
	曾患疾病和传染病史：□无　□有：
	外伤史：□无　□有：
	手术史：□无　□有：
【个人史】接触史：□无　□有(□毒物　□化学物品　□放射性物质　□其他：
	嗜烟(□无　□有)约____________________年，平均____________________支/d。戒烟(□未　□已)约________________年
	嗜酒(□无　□偶有　□经常)约____________________年，平均____________________两/d
【家族史】□无 □有：
患者信息及病情核对：以上内容已经仔细阅读，情况属实，医师告知充分。并充分了解医师拍摄本人创面照片用于诊疗和案例分析等学术用途。患者或家属确认(签字)：________________
Part B：病史采集客观内容
一、体格检查
体温__________脉搏__________呼吸__________血压__________
临床医师通过视、触、扣、听及嗅的方法了解和评估患者身体状况。主要包括生命体征和一般检查，按照头、颈、胸、腹、脊柱、四肢和神经系统顺序，必要时也可进行生殖器、肛门和直肠检查。

Part A：病史采集主观内容
入院日期____________________记录日期____________________
姓名__________年龄__________职业____________________现住址__________________________单位____________________
性别：□男 □女婚姻：□已婚 □未婚 □离异供史者：□本人 □家属 □其他
【主诉】应在病历管理系统中简明扼要(20字以内)、专业规范地表述创面症状、阳性体征及症状持续时间。创面症状代表：局部情况如红肿热痛、渗出等，阳性体征代表：全身情况如发热等。
【现病史】应按时间顺序记录创面的发生、演变、诊疗等方面情况。具体包括一般情况、创面形成的时间、原因、发展变化情况、有无新症状出现、诊疗经过及效果。一般情况即目前精神、饮食、睡眠、大小便、体重及活动能力等情况。
【既往史】健康状况：□良好　□一般　□较差
	过敏史：□无　□有，过敏原：
	曾患疾病和传染病史：□无　□有：
	外伤史：□无　□有：
	手术史：□无　□有：
【个人史】接触史：□无　□有(□毒物　□化学物品　□放射性物质　□其他：
	嗜烟(□无　□有)约____________________年，平均____________________支/d。戒烟(□未　□已)约________________年
	嗜酒(□无　□偶有　□经常)约____________________年，平均____________________两/d
【家族史】□无 □有：
患者信息及病情核对：以上内容已经仔细阅读，情况属实，医师告知充分。并充分了解医师拍摄本人创面照片用于诊疗和案例分析等学术用途。患者或家属确认(签字)：________________
Part B：病史采集客观内容
一、体格检查
体温__________脉搏__________呼吸__________血压__________
临床医师通过视、触、扣、听及嗅的方法了解和评估患者身体状况。主要包括生命体征和一般检查，按照头、颈、胸、腹、脊柱、四肢和神经系统顺序，必要时也可进行生殖器、肛门和直肠检查。

第1诊断：创面名称	□糖尿病足　□压力性损伤　□动脉性溃疡　□静脉性溃疡　□癌性创面　□放射性溃疡　□药物性皮肤溃疡　□结核性溃疡　□特殊细菌感染性创面　□痛风石创面　□医源性创面□其他创面
创面部位		分期
第2诊断：引发的疾病
创面评估分数	入院时	入院后1周	入院后2周	入院后3周

第1诊断：创面名称	□糖尿病足　□压力性损伤　□动脉性溃疡　□静脉性溃疡　□癌性创面　□放射性溃疡　□药物性皮肤溃疡　□结核性溃疡　□特殊细菌感染性创面　□痛风石创面　□医源性创面□其他创面
创面部位		分期
第2诊断：引发的疾病
创面评估分数	入院时	入院后1周	入院后2周	入院后3周

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