Re: [问题] 请问病历哪种写法上法院比较惨?

楼主: proudC (call me 酷哥)   2018-08-14 20:34:07
目前看起来似乎是简单写乐胜
GAN,那当初clerk在学写病历是87吗?
换个情境好了
如果还是偏向简单写以后我就真的要改习惯了
病人因胸痛来急诊,EKG 和心肌酵素都正常
1.Atypical chest pain
处方 : propanolol 10 mg TID
aspirin 100 mg QD
CV OPD 3 天后
Inform risk of sudden death
2.Anterior chest pain for 2 days, mild, stabbing-like, intermittent,
last seconds to minutes, without radiating. sometimes onset when watching TV,
minimally aggravated by exertional activity,
more frequently in recent days, feeling more stressful recently
处方 与上面一样,也约回诊也告知 sudden death风险
结果病人回去隔天就 OHCA
简单写还会乐胜吗 ? 还是在鬼岛都该死 ?
作者: whitezealman   2018-08-14 22:35:00
理论上是简单乐胜 多写多错 但重要的sign跟处置要带到 重点是要记录事实 以及减少上法院时被挑剔的机率

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