The doctor " The book from heaven " When can the case history patient understand?

The doctor " The book from heaven " When can the case history patient understand?
From March 1, " the case history writes the basic norm " to begin to implement for the new edition revised by Ministry of Public Health, stipulate in " norm " clearly: "The doctor writes the case history 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 accurate. " The new regulation is implemented for over one week, is the doctors' overbearing grass case history improved to some extent? March 9, in reporter visit and investigate, patient large to shake their head, call and can not understand " book from heaven " even Case history. "Write too hasty and carelessly, except hospital name and date, the other one does not basically know. " Will it be morning 9, outside the intersection of province and the intersection of the People's Hospital and the intersection of internal medicine department and clinic, finish watching Tian of disease recognize the word at the case history in the corridor carefully by Mr. and wife just. "Such about 100 words, only recognize several intermittently, why matter is this stomach on earth? How did the doctor say? " The wife on one side holds the case history that can not be understood to ask Mr. Tian worrying about. "Big problem that should be nothing. " Mr. Tian does not certainly answer. "Otherwise I will enter to ask in a moment, will come once with great difficulty. " The wife says worrying. The reporter sees, on Mr. Tian's case history, the diagnosis result that the doctor fills in is hasty and more careless, there is not any punctuation mark among the sentences. Mr. Tian says, while entering the clinic, the nurse does not allow the wife to enter together, the doctor told him the condition at that time, but the medical terminology that doctors spoke remembered, can finish forgetting soon once coming out at that time by oneself too much.
Leaf through ten more than case history of patient this in this institute the intersection of outpatient building and reporter, except that the writing of 3 case histories is careful and neater, most case history writing hasty and careless, a lot of words connect with the pen and write the unable broken word together. Patient Mr. Qin says to reporters: "What word I graduate from university too, the education are not too low, but but can not understand this that they write. Last time, the medicine which doctors prescribed, the dispensary was out of stock, I bought on the pharmacy opposite to the outlet, persons in the pharmacy have watched a circle in turn, has not recognized either that is the medicine, finally, ask what disease I see, can just roughly guess it is man amine kanamycin. "
Subsequently, the reporter comes to several pharmacies opposite to this hospital again, the sales force of the pharmacy scratches one's head to the great sense of prescription that the hospital doctor opens. "We will meet the prescription that can not be understood every day basically, sell the long time of medicine, mostly ask at time what disease the patient sees, can guess one is very near. Can have, really sure. " A sales force says.
As to " book from heaven " Case history, most experts admit writing by oneself while interviewing. They say frankly, it is out of question to write the case history normally at ordinary times, when can go out and examine, because there are many patients, time is tight, the speed that accelerate writing unconsciously, the script is more or less hasty and careless, it is unavoidable too. "Sometimes can not really manage. " An expert insisting on anonymity says to reporters: "When being the busiest, will see ten or twenty patients in an hour, how much time is there to spend in writing? However, connecting it while examining, we will all tell condition and prescription to the patient carefully. Besides, all include the specialized term of a lot of medical science in the case histories and write absolutely clearly, the patients may not all see clearly either. "
Chief of Taiyuan Municipal Health Bureau Li WenXue introduces, carries out " the case history writes the basic norm " strictly, can improve the intersection of case history and quality, ensure medical quality and security, can also reduce doctors and patients both sides, because understand the mistake for causing a dispute, this pair of doctors and patient both sides are beneficial. March 8, the case history " one is open " implemented in Taiyuan ,Also standardize a doctor and write a method of the case history. "The unified case history requires medicines to be common names, the doctor should sign the full name on the case history, can't replace with the symbol again. Form the mechanism of supervising mutually in this way, each prescription which doctors makes will accept different hospital doctors ' check ', in this way, the doctor will disappear to some extent while writing the case history of ' the overbearing grass ', making the great prescription. "
Staff reporter Liu Xia
|