1) Routine case record
手写病历
2) medical records writing
病历书写
1.
Medical records writing is indispensable in the clinical practice,and it is also the clinical skills that interns must have.
病历书写是临床实践中不可缺少的工作,也是实习医师必须掌握的临床技能。
3) medical record
病历书写
1.
Based on the experiences of clinical quality control and check of the medical record for many years,we discussed the impaet and requirement of the diagnosis which acts on clinical medicine,and analyzed the types,requirement,format,and others related to the diagnosis.
在现有的病历书写规章制度中,有关诊断的书写标准和要求不够完善和规范,因而也限制和影响了临床医师的思维和书写。
2.
The rules and regulations of documentation of the medical record concerning the definition of the chief complaints and their criterion should be changed and developed in order to adapt the constant changing of medicine service.
文章提出了在医院医疗服务范围和项目不断拓宽的情况下,现行病历书写规章制度中有关“主诉”的定义和书写要求也应进一步修改和拓宽。
4) Non-surgical case
非手术病历
5) The Specification of the Documentation of the Medical Record
病历书写规范
1.
The Pre-post Training of The Specification of the Documentation of the Medical Record and the Evaluation of the Result;
新进临床医师《病历书写规范》岗前培训与考核成绩评价
补充资料：病历
1.医疗部门记载病情﹑诊断和处理方法的记录。每个病人一份。
说明：补充资料仅用于学习参考，请勿用于其它任何用途。
参考词条