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临床医学
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病历书写     
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  medical record writing
     Objective To analyze the problems in medical record writing so as to provide facts for the improvement in medical record writing's quality.
     目的分析病历书写中存在的问题,为提高病历书写质量提供依据。
短句来源
     Objective To improve the quality of the medical record management and that of the documentation medical record writing.
     目的提高病案管理质量,提高病历书写质量。
短句来源
     SNOMED CT designed the reasonable hierarchy of medical concepts, settled the semantic relationships between concepts, which efficiently improve the quality and efficiency in medical record writing, medical information transferring and standardized management.
     依据现代医学理论指导,SNOMED CT将海量的临床医学术语进行了较合理的概念分类,构建了概念间的语义关连,有效地提高了临床电子病历书写、医学信息传递与标准化管理等工作的效率与质量。
     1. The evaluation contents of the four hospitals are not uniform and normative, with theory check, operation estimation and medical record writing predominating, ability appraisal accounting for little.
     1.四家附属医院本科护生的实习评价内容不统一、不规范,以理论考核、技术操作及病历书写为主,以能力为主的考核内容所占的比例较少。
短句来源
     Results The health education effects, patients satisfactory degree and medical record writing quality raised obviously.
     结果  2 0 0 2年健康教育效果、病人满意度及护理病历书写质量均较 2 0 0 0年明显提高 ;
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  medical documentation
     Methods According to the "writing standards of medical documentation in Fujian Province"(revised edition in 2003) and the actuality of our hospital,and aimed at the problems in nursing records,we integrated the different nursing records sheets into one nursing records sheet,and standardized the writing of nursing records.
     方法依据《福建省病历书写规范》(2003年修订版),针对原来护理记录存在的问题,结合我院实际,制订了包括取消多种记录单改为单一护理记录、将所有记录直接在护理记录单上体现的制度,同时规范护理记录的书写。
短句来源
  records writing
     A survey and analysis of status quo of nursing records writing
     护理病历书写状况调查与分析
短句来源
     To unfold activity of "one, two, four, four", to enhance quality of nursing records writing
     开展“一二四四”活动 提高护理病历书写质量
短句来源
  case history writing
     Objective To design simple and suitable clinical nursing tables and administrative standards to meet the requests of nursing record, “medical accident handling regulations(regulations)” and “criterion of case history writing (criterion)”.
     目的设计一套简单、适用的临床护理表格 ,以达到《医疗事故处理条例》(下称《条例》)和《病历书写规范》(下称《规范》)对护理记录的要求。
短句来源
     In view of some legal problems arising in clinical practice of tooth and endodontics,we propose increasing the legal consciousness in clinical practice teaching,strengthening humanistic care and risk management,and standardizing case history writing. This will ensure the orderly,efficient and safe process of clinical practice teaching of tooth and endodontics.
     针对牙体牙髓病学临床实习过程所涉及的法律法规问题,提出在牙体牙髓病学临床实习过程中应将法律意识融入教学行为,加强人文关怀,加强临床实习的风险管理及规范病历书写,以确保牙体牙髓病学临床实习教学有序、有效、安全地进行。
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      medical documentation
    Introduction: Medical documentation is important for communication among health care professionals, research, legal defense, and reimbursement.
          
    Structural demands on computer-based medical documentation in the hospital setting
          
    Design: Prospective observational time analysis during medical documentation tasks.
          
    Problems of medical documentation and statistics are discussed in relation to the value of sequential analysis.
          
    For all patients medical documentation, in the form of clinical history and physical examination, confirmed that a visible hematoma was present acutely at the same location following the injury and that the contour deformity subsequently appeared.
          
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    One of the distinct characteristics in dynamic Whole Case Management is to give fullplay of the

    动态《全病历计算机管理系统》一个鲜明的特色就是预选技术得到全面发挥性应用,预选病历有助于解决病历书写的自动化、快速化、标准化。医嘱预选、药物预选、方剂预选保持了系统内部的一致性,并大大地简化了操作,减少了击键次数,原先繁琐、复杂的工作变得轻松自如。预选技术化难为易,化繁为简,化不能为可能,化平凡为神奇。

    The obstetrical quality has been checked in 5 MCH institutes, 6 hospitals in town, 11 hospitals in county and 11 hospitals in village. The main contents of the checking for the units in county and town are scientific management, medical ethics, work of the outpatient service and emergency call, the system management of pregnant women and puerperants, work of the ward, labor room and delivery room, professional advice for basis units. The contents of the checking for the hospitales in villege are scientific management,...

    The obstetrical quality has been checked in 5 MCH institutes, 6 hospitals in town, 11 hospitals in county and 11 hospitals in village. The main contents of the checking for the units in county and town are scientific management, medical ethics, work of the outpatient service and emergency call, the system management of pregnant women and puerperants, work of the ward, labor room and delivery room, professional advice for basis units. The contents of the checking for the hospitales in villege are scientific management, the installations of obstetrical department, obstetrical knowledge, medical history writing, rules and regulations, disinfection and isolation, breast feeding, system management of pregnant women and puerperants, statistics work. The results shown that the obstetrical quality in the 33 units is good, the obstetrical quality of the village hospitals has rapidly improved. The authores think that the basis training of the medical staff should be strengthened and import in order to cutting down the rate of Caesarean birth.

    浙江省卫生厅妇幼处对5所市地级妇幼保健院、6所市地级综合医院、11所县级综合性医院、11所乡镇卫生院进行了产科质量检查。县级以上医疗保健机构妇产科检查的主要内容为科学管理和医德医风、门急诊工作、孕产妇系统管理、病房工作、待产室和分娩室工作、对基层业务指导等;乡镇卫生院妇产科检查的内容为科室管理和产科设置及装备、产科知识、病历书写、规章制度及消毒隔离、母乳喂养、孕产妇系统管理、统计工作等。结果显示,33所医疗保健机构的产科质量是好的,特别是乡镇卫生院的产科质量有了较快的提高。笔者提出了今后应加强各级医疗保健机构的妇产科医护人员的“三基”训练,加强技术人才的培养和引进,降低剖宫产率的措施。

    in view of nursing-related problems in the writing of holistic nursing casehistory and the issues existing in nursing measures and nursing evaluation, the nurse's holistic points were strengthened with continuous analysis, discussion and summarization. The recording form of P. I. O. which could not only show the whole situation of the patient, but also realize the completely uninterruptedly nursing process to the patients was developed.

    针对整体护理病历书写中有关护理问题、护理措施、护理评估等方面存在的问题,通过强化护士的整体观念,不断地分析、研讨和总结,形成了既能反映病人整体情况,又能体现对病人连续护理的全过程的“P.I.O”记录形式。

     
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