2010年4月21日

病歷的書寫方式by炯爹

Run完GI後,若要說對我最大的影響的話,應該是書寫病歷的模式吧!
以前總是以為把自己Open questions加上past history等等的一股腦記錄成電子檔便好
炯爹替我第一次修Admission note就灌輸了好多新的觀念進來

整個AD Note最花心力的兩個地方就是Present illness及Assessment & Plan:
Present illness分四段書寫:
  1. 病人Underline disease及Background health status
  2. 這次來的symptoms描述 (positive finding)
  3. Differential diagnosis (用negative finding來排除一個個疾病)
  4. 在ER或OPD做的處置及檢測結果
最後面Assessment & Plan 的部分,則跟Problem list息息相關
我之前Problem list總是只寫疾病或診斷 (如Liver cirrhosis)
可是這樣寫就比較容易忘記接下來要check哪些lab及該做哪些處置,A&P亂寫

炯爹告訴我們:
Problem list要寫:
Organ+ Diagnosis+ Etiology+ Prognosis+ Complications
(如: Liver cirrhosis, HBV related, Pugh C, EV bleeding s/p EVL
這樣寫Problem list,除了知道這個病更多資訊外,我就知道接下來要測Bilirubin, albumin, PT(INR), Ascites, Encephalopathy來算Child-Pugh score;看是否有tarry stool來監測是否有 EV rebleeding等)

接著A&P要注意的:
Assessment:
  1. AD的話,寫憑什麼下這個診斷
  2. Progress note寫
    Worsening, stationary/stable, improving, improved四選一
Plan:
  1. Diagnostic: 3C-confirm, complete, course
  2. Therapeutic: Medication, Intervention, Indication, Contraindication
  3. Educational: Medical counseling, Prognosis, Further care, Ethics



 2011 1/29補充:Admission order格式 (口訣:ADC VAAN DIML)

Admitted under the service of Dr. House
Diagnosis:
Left pleural effusion, suspect empyema
Diabetes Mellitus type II with neuropathy
Alcoholic liver disease
Condition: Serious
Vital sign: QID
Activity: Out of bed to chair
Allergy: NKDA
Nursing:
record chest drainage QD, Finger stick for sugar 4 parts
Diet: DM diet 1800 cal
IV:
N/S 500 ml + KCl 10 meq QD; D5W 500 ml + KCL 10 meq + RI 5U QD
Cefoxitin 1 gm IV Q6H
Thiamine(100mg) 1 amp IV QD
RI scale if sugar higher than 250 mg/dL
Medication:
Glibenclamide(5mg) 1# bid,
Glucophage(500mg) 1 tid
Ativan (0.5mg) 1# hs
Laboratory:
Check CBC, D/C, ALT, Cr, Na, K QW1, 4
CxR on next W1
Check GGT, Alk-p, HBsAg, HCV Ab, HbA1c st.
Arrange abdominal sonography
ECG, U/A
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