The electronic case history was implemented from March 1 Doctor's " book from heaven " It is expected to be terminated
Mentioning the case history, there has been the first response of citizen who has sought medical advice and gone through not to " understand " to believe the great majority ,Above characters just like " The book from heaven " . On March 1, " the case history writes the basic norm " that Ministry of Public Health prints and distributes on February 4 this year will be implemented formally, after this " norm " is implemented, the case history looks like " book from heaven " State can to some extent change? Whether the electronic case history can become a doctor " The book from heaven " Terminator?
New rule: The case history is wanted when being written " The writing is clear "
"Go to the hospital to see the doctor each time, I can not understand the word which the doctor writes on the case history, see, desire, see doctor write anything at case history, want, ask doctor afraid of, delay other time that people diagnose the illness also after being ill. "
It is said the new rule that the case history writes should be issued, a yellow young lady of many patients' citizens says in home, what she wanted to understand most is - --Whether this new rule has stipulated the doctor when writing case history, the writing wants carefully and neatly.
" the norm ", in the full text, chapter one article 6 make the following regulation to characters at the case history: "The case history writes and uses the medical terminology in conformity with the norm, the characters are careful and neat, the writing is clear, it is accurate to state, the sentence is clear and coherent, the punctuation mark is correct. "
Hospital: It is very difficult to make sure to let the patients all understand
The reporter has interviewed the relevant persons in charge of several large hospitals in Xiamen, most people think, though new rule has characters carefully and neatly, the writing is clear,etc. stipulates, in the course of implementing, the intersection of doctor and handwritten case history, or very difficult to make sure, let each patient can understand.
The reporter knows from the first hospital in Xiamen, the form that it is the electronic case history that the case history is adopted in hospital in all of this institutes at present, do not exist " The book from heaven " Question,so,"book from heaven" Problem existence mainly at clinic for case history, in the middle.
"A doctor should see more than 100 patients sometimes in one day, the time that each patient saw the doctor has been already very short, if also want, afford to draw by one and a half sum of, estimate, take, watch little patient again. " The first hospital medical matters department director Su ZhiYing think, everybody's script was originally different to some extent, combine with the medical terminology more, it is unavoidable that the patient can not understand.
Hope to find out about the psychology of the condition through the case history as to many patients, subsidiary Vice President of hospital of Zhongshan Zhang ZhenQing of Xiamen University points out, case history whether medical worker launch record that medical treatment work, its main target or medical worker that directs against, the patient wants to find out about one's own condition, the most basic, should communicate with the doctor more.
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