主任查房记录（Chief ward round record）.docVIP

主任查房记录（Chief ward round record） The hospital is now the general requirements in 1 weeks must have more than 2 physician rounds, more than 1 times of the subtropical high over the first rounds records (deputy chief physician) rounds and physician rounds must be detailed, in general should have the following contents: 1., the patients consciousness, body position and vital signs are stable, whether the ventilator and booster are applied or not, and there are no complaints about defecation and defecation. (this section is essential for the daily course notes, and will be remembered at the beginning of the course of the disease.). The basic situation of 2. patients (age, gender, work), complaints, history review, mainly related to chronic disease history, critically ill after consultation, and transferred into the branch, after the basic vital signs, mainly positive signs and important auxiliary examination results. 3. the vital signs and main positive signs: this part is the objective data, director rounds if there is mention of what important, special or newly discovered system must focus on the description of characteristics, this part is objective, accurate and concise. If there is a big difference between the superior doctor and his own physical examination, it is necessary to repeat and highlight the bedside examination again to confirm that the results are generally based on the higher physician. 4., higher physician rounds record: general content of the above 2 and 3 as objective content description, and superior physician rounds of the disease analysis as a subjective part, the general format for: Today with the XXX (director) (deputy chief physician) rounds, carefully review the medical records and various auxiliary examination results, look after the patient bedside analysis: the elderly men, a brief history of major complaints, positive signs, positive auxiliary examination results, according to the patients medical history, symptoms, signs and auxiliary exa