Title: The writing of clinical record
1The writing of clinical record
Department of Gastroenterology Ren-Ji Hospital
Prof. Zhi Hua Ran
2- A patients health record plays many important
roles and provides a view of the patients health
history/status
3The basic requirement of clinical records
- In writing up the history and the physical
examination, the examiner should obey the
following rules - Record all pertinent (???) data, avoid
extraneous (???)data - Use standard format
- Describe comprehensively, use common terms,
avoid - nonstandard abbreviations(??)
4The basic requirement of clinical records
- Written in an all-round way, all items should be
filled, - the hand writing should be clear, not
scratchy(??) - or be altered
- Be objective(??), use diagram(??) when
- indicated
5Types , formats and contents of clinical records
6Clinical records during hospitalization
- The clinical records should be written during
hospitalization - It includes
- Case record
- First record of admission
- Record of the course of disease
- Record of consultation
- Record for transferring to new department
- Record of discharge
- Record of death
- Record of surgery
7Case record
- The case record should be written systemically
and completely within 24 h by intern
8Formats and contents of case record
- Case record
-
- Name Sex
- Age Marital
status - Nation
Profession - Native place Current
address - Data of admission Data of case
record - Source
Reliability
9- Chief compliant
- History of present illness
- Past illness
- Systemic review
- Personal history
- Marriage
- Reproductive and Gynecologic history
- Family history
10Physical examination
- Temperature Pulse
Respiratory Blood Pressure -
- General appearance
- development,
- nutrition (well, moderate, poor)
- facial expression (acute or chronic,
suffering expression, anxiety, - fear,
calm) - position, gait
- mental status alert,
obscure(????), -
lethargy(??), coma - cooperative
11Physical examination
- Skin and mucous
- color (reddish, paler, cyanosis,
yellowish, pigmentation) - swelling, moisture, elasticity,
bleeding, rashes, subcutaneous - nodular, spider angioma(???),
ulceration, scar. - The location, size and shape should be
recorded. - Lymph note
- systemic or localized lymph notes
- (submaxillary, ??posterior auricular,
???neck, - armpit, ??groin,???).
- Its size, number, tenderness, hardness,
mobility, fistula(??), - scar etc.
12Physical examination
- Head and organs
- Head its size, shape, tenderness, mass, hair
- Eye eyebrow(??), eyelash(??), eyelid,(??)
- eyeball (protrude/??, sunk/??,
movement, tremble/??, - strabismus/??),
- conjunctiva(??), sclera(??),
- cornea/?? (size, shape, symmetry,
light reflex, near reflex). - Ear discharge, hearing, mastoid(??).
- Nose abnormality tenderness of maxillary
sinus(???), ethmoid sinus(??), frontal sinus(??)
exudation(??), bleeding.
13Physical examination
- Oral cavity odor, lips (color, swelling,
ulceration, herpes simplex, - pigmentation) teeth
gingival(??) - tongue (mass,
ulceration,coating of the tongue, - mucus (rash, bleeding,
ulceration) - tonsils(???) pharynx(?)
etc. - Neck symmetry texture (slightly
flexed and cradled in the - examiners hands) thyroid
gland (size, hardness, - tenderness, nodular,
tremble, murmur) superficial venous - distention the position of
the trachea.
14Physical examination
- Chest configuration symmetry local protrude
tenderness - respiratory rate and pattern
- abnormal pulsate(????)
- breast (size, mass) venous
distention
15Physical examination
- Lung
- Inspection respiratory movement
interspace of ribs - Palpation the extent of chest
excursion(??) vocal fremitus - (??)
- Speech creates vibrations
that can be heard when one - listens to the chest and
lungs. These vibrations are - termed vocal fremitus.
When one palpates the chest wall - while an individual is
speaking, these vibrations can be - felt and are termed
tactile fremitus(????). - Pleura friction(?????)
- subcutaneous
crepitus(???).
16Physical examination
- Percussion resonance tympany
- hyperresonance
dullness - flatness
- diaphragmatic movement
- Auscultation breath sounds
- tracheal
- bronchial
- bronchovesicular
- vesicular
17Physical examination
- Heart
- Inspection apical impulse, or its
location, area and intensity - Palpation assessing point of maximum
impulse, thrills, fremitus - Percussion percuss the hearts borders,
the relative dullness or - absolute dullness
borders - Auscultation the heart rates, rhythm,
heart sounds, - murmur(??),
abnormalities of the S1, S2, - splitting of S2,
systolic clicks, diastolic opening snaps, - vocal fremitus,
premature beats(??)
18Physical examination
- Radial artery (???)
- pulse rate, rhythm
(regular or irregular), - pulse deficit(????).
- The pulse may be described as normal,
diminished, - increased, or double-peaked.
- Peripheral vascular signs capillary strike
signs, -
bruits(??), -
abnormal artery movement.
19Abdomen
- Inspection symmetry, size, abdominal
distention, - pitting (concave
abdomen), - respiratory movement,
skin lesion, - pigmentation, surgical
scar, umbilicus, - hernia(?), body hair,
venous distention and - direction of blood flow,
peristaltic waves(???) - ecchymoses (??)
- Palpation the tenderness of abdominal wall,
rebound - tenderness, mass
(location, size, shape, texture, - tenderness, motion,
mobility)
20Abdomen
- Liver size, character, surface, edge,
tenderness, motion. - Gallbladder size, shape, tenderness
- Spleen size, character, tenderness,
surface, edge - Kidney size, shape, character, tenderness,
mobility - Bladder distention (??)
- costovertebral(???) angle
tenderness
21Abdomen
- Percussion liver dullness borders, hepatic
tenderness over - the right upper quadrant,
- shifting dullness (?????)
- Auscultation bowel sounds(???), vascular
bruits - Anus and rectum anal fissure (??)
- anal fistula
(?? ) - pile(?)
- digital rectal
examination(????)
22Genitalia
- Male pubes(??), penis(??), glans(??)
- scrotum (??), testicles (??),
epididymis(??), - Female
- External
- pubes, vagina(??), urethral
meatus(???), - hymen(???), labia minora (???),
- labia majora (???), clitoris(??)
- Internal ovary(??), uterus(??),
- fallopian tube (???)
23Physical examination
- Spine tenderness, abnormal spinal
extension/rotation, - lateral deviation
- Extremities deformity, venous distention,
stiffness, - limitation of motion,
joint, strength
24Physical examination
- Nervous system
- biceps tendon reflex (?????)
- triceps tendon reflex (?????)
- patellar tendon reflex (????)
- Achilles tendon reflex (????)
- abdominal superficial reflex (????)
- cremasteric superficial reflex(????)
- test for abnormal reflexes
- babinski sign, chaddocks sign,
hoffmanns sign
25Physical examination
- Specialized subject
- such as surgery
-
ophthalmology (??) - gynecology
(???)
26Laboratory and other special examinations
- Laboratory tests
- record all those data that are associated
with diagnosis, - including three routing tests and other
laboratory tests - 24 h after admission.
- Special exam gastroscopy, barium enema, X-ray
etc.
27Summary
- Combining with the case history, physical
examination and laboratory data, propose the
evidences of diagnosis, and - finally set up the diagnosis
- Preliminary diagnosis
- Signature or stamps
28Common medical documents
- Record of admission
- Record of the course of disease
- Record of consultation
- Record for transferring to new department
- Record of discharge
- Record of death
- Others
29Record of admission???
- The record of admission is the abstract form of
full case - record. The key points should be emphasized,
and it - should be written concisely(??) or
compendiously(??), and should be finished with 24
h after admission by resident -
- The chief complain and present illness are
written in the - same form as full case record, the others
could be - written in the short form, without the
abstract.
30The format and content of record of admission
- General information of the patient
- Chief complaint
- Present history of illness
- Past history in summary
- Physical examination
- Vital signs
- General appearance and systemic organs
- Laboratory tests
- Preliminary diagnosis
- Signature
31Record of the course of disease????
- It records the progression and treatment of the
whole - courses of patients disease during ones
admission. It - should be recorded with trueness, promptly,
with - prospective analysis. It actually reflects the
quality of - the medical treatment.
- It can be written once a day according to the
changes of - the disease. For those severe cases, it should
be written - several times per day. For those patients with
mild - illness, however, it could be written every
23 day.
32The content of records are generally including
- The patients complains (about his/her
discomfort, - moods, physiological status, food, sleep,
relieve oneself, - those can be further selected according to the
need for - the progression of the disease.
- The changes of disease, including signs and
symptoms, - or any new discovery, the results of various
laboratory - or other adjuvant examinations, the analysis,
evaluations, - or remarks on those data.
33The content of records are generally including
- The records of various manipulations, such as
plural - puncture, abdominal puncture, lumber puncture,
- endoscopy, cardiac catheter exam, various
radiography. - Reinforce or amend the clinical diagnosis, amend
the - evidences for the diagnosis.
- The opinion of senior doctor about the diagnosis
and - differential diagnosis.
- The treatment, drug use and its efficacy or side
effects. - Opinion of consultation of other department.
34The content of records are generally including
- Information from patients relatives (their
hope, desire, - and reflection the information that the doctor
induced to - the patients relatives
- Monthly brief phase summary
-
- Time of record and signature
35The first record of the course of disease ?????
- The first record of the course of the disease
should be recorded at the same day as admission,
its content and format are different from that of
other record of course of the disease, including - ? patients name, sex, age, chief complain,
prominent - signs and symptoms, results of those
adjuvant - examination, that are highly summarized and
- emphasizing the key profiles.
36The first record of the course of disease?????
- ? Propose the preliminary diagnosis, differential
- diagnosis and their evidences, based upon
above data. - ? Propose some other special examinations in
order to - further confirm the diagnosis
- ? Propose the treatment and diagnostic planning
- according to the actual situation of
patients illness on - admission
37Record of consultation ????
- If the patient presents other system disease, or
- symptoms difficult to diagnose, other
specialist may be - invited for consultation.
- In general, the consultant opinion will be
written in - consultant sheet.
- The consultant opinion includes brief
description of case - record, specialized examinations, the analysis
and - diagnosis of the disease, propose his opinion
for further - more precise examinations.
38Record of consultation
- If the opinions are collectively, record all
those doctors - participating the consultation, their
analysis, - examination, and treatment.
39Record for transferring to new department????
- During the periods of hospitalization, the
patient may - present symptoms of other systems
(department). With - the approval of doctor of other department,
the patient - can now be transferred to the new department.
- It can be written in the record of the course of
diseases - sheet.
- The content may include the major cause of
disease, - treatment, the reasons for transferring, the
precaution - notes etc.
40Record for transferring to new department
- If the patient is transferred from other
department, - resident should write the record of
transferring, the - content of the record is similar to that of
record of - admission.
41Record of discharge????(????)
- When the patient is going to be discharged,
the record of discharge should be written, and
give to the patient on the data of discharge. The
content includes - Name, sex, age, diagnosis on admission, data of
- admission, diagnosis on discharge, data of
discharge, - days of hospitalization.
- Various numbers of special examination (number
of - hospitalization, number of X-ray, CT,
pathology, EKG - etc.
42Record of discharge????(????)
- Briefly introduce the reason of admission,
present - illness, the data of major examinations, the
progression - and treatment of the disease during
hospitalization. - The condition of patient on discharge, including
signs - and symptoms, results of major examination and
- treatment (recover, improve, no effect,
exacerbate, - complication).
- The treatment advice on discharge, notes for
precaution
43Record of death????
- The record of death should be recorded
immediately - after death of patient. The content and format
of death - record are similar to that of discharge
record. It includes - case summary, hospitalization, diagnosis and
treatment, - the causes for diseases progression, the
rescue course, - time of death, causes of death, and final
diagnosis.
44Record of death????
- For all death patients, particularly those cases
the - diagnosis are uncertain, one should persuade
the - relatives of death patient to perform the
autopsy, the - anatomicalpathological results will be also
recorded.
45Others
- The routine medical documents also include
summary - of preoperation, record of post-operation,
record of - surgery etc.
- The format is consistent with the record of
course of - disease.
- Summary of pre-operation may emphasize to record
the - disease condition, reasons of operation, types
of - operation, the possible complications/situations
occurred - post-operation, and methods toward to these
- complications.
46Others
- Post-operation records should record the
condition of - surgery, findings during surgery, name of
surgery, - disease progression during surgery, types of
anesthetics, - response of anesthetics, treatment advice for
post- - operation etc.
- The record of surgery should be written by
surgeon who - performed the surgery.
47Case record of readmission ??????
- If the patient is readmitted, the number of
admission should be noted in the case record. It
may also include the following contents - If the patient is readmitted for the same
disease, it is - necessary to record the case summary of the
past and - the outcome of the disease between last
discharge and - current readmission. Whilst the past history,
systemic - review and personal history can be further
summarized - or even be neglected. The new condition should
be - added.
48Case record of readmission??????
- If the patient suffered from a new disease, the
case - record should be written according to the
format of first - case record. The past disease can then be
categorized - into past history or systemic review.
49Table format of case record
50Case record of out-patient ????
- It should be written with perspicuity(??),
stressing on the keystone - The diagnosis can be made after the patients
first visit - to physician or further consultation with the
physician. - If the definite diagnosis cant be made, the
patient can - be treated as symptom causes unknown, such as
- abdominal pain causes unknown, fever of
unknown - origin. In addition, one or more suspected
diagnosis - can also be made.
51Case record of out-patient--- requirement
- In the department of emergency, the record
should - include the precise time of consultation.
Apart from the - present history of illness and most important
signs, the - vital signs including BP, pulses, breath
rates, - temperature, conscience, treatment regimes,
and course - of treatment. If the treatment is failed,
e.g., the patient - died, time of death, diagnosis and causes of
death - should be also included.
- Signature of the physician (hand writing, or
stamp)
52Case record of out-patient---content
- The cover should be filled with patients name,
sex, age, - marriage, profession, address, numbers of some
- important examinations (such as X-ray, ECK, CT
et al), - telephone number, drug allergy
- Day of the service
- Chief complaint
- History of illness (present, associated past
history, - personal history or family history)
- Physical examination (positive signs and
important - negative signs)
53Case record of out-patient---content
- Laboratory examinations or special examinations
- Preliminary diagnosis
- Treatment (further exams, drugs, time,
suggestions) - Signature
54Diagnostic reasoning in physical diagnosis
- This is one of the most important topics in the
clinical - diagnosis, because it considers the methods and
- concepts of evaluating the signs and symptoms
involved - in diagnostic reasoning.
- The primary steps in the process involve the
following - Data collection
- Data processing
- Problem list development
-
55Data collection????
- Data collection is the product of the history
and the - physical examination. These can be augmented
with - laboratory and other test results such as blood
- chemistry profiles, complete blood counts,
bacterial - cultures, electrocardiograms, and chest x-ray
films. - This history, which is the most important
element of the - database, accounts for more than 70 of the
problem - list.
56Data processing????
- Data processing is the clustering of data (????)
obtained from the history, physical examination,
and laboratory and imaging studies. -
- To fit as many of these clues together into a
meaningful pathophysiologic relationship. - Hypothesis(??)
- Impression(??)
- Primary diagnosis(????)
57Data processing????
- For example, suppose the interviewer obtains a
history - of dyspnea (????), cough (??), earache (??),
and - hemoptysis (??).
- Dyspnea, cough, and hemoptysis can be grouped
together as - symptoms suggestive of cardiopulmonary disease.
- Earache does not fit with the other three
symptoms and - may indicate another problem.
58Problem list development
- Problem list development results in a summary of
the - physical, mental, social, and personal
conditions - affecting the patients health.
- The problem list may contain an actual diagnosis
or - only a symptom or sign that cannot be
clustered with - other bits of data.
- The data on which each problem developed is
noted. - This list reflects the clinicians level of
understanding of - the patients problem, which should be listed
in order of - importance.
59Problem list development
- The presence of a symptom or sign related to a
specific - problem is a pertinent positive.
- For example, a history of gout and increased
uric acid - level are pertinent positives in a man
suffering from - excruciating back pain radiating to his
testicle. - This patient may be suffering from renal colic
secondary to - a uric acid kidney stone.
60Problem list development
- The absence of a symptom or sign that, if
present, would - be suggestive of a diagnosis is a pertinent
negative. - A pertinent negative may be just as important as
a - pertinent positive the fact that a key
finding is not present - may help rule out a certain diagnosis.
- For example, the absence of tachycardia in a
women with - weight loss and a tremor(??) makes a diagnosis
of - hyperthyroidism less than likely the presence
of - tachycardia would strengthen the diagnosis of
- hyperthyroidism
61Diagnostic reasoning?????
- Unfortunately, decisions in medicine can be
rarely be - made with 100 certainty
- Probability(???) weights the decision
62Others
- Sensitivity and Specificity
- Likelihood ratio
- Ruling in and Ruling out Disease
- Positive and Negative Predictive Values
- (???????????)
- Prevalence
63Decision analysis
- Diagnostic reasoning is only the first step in
clinical - decision-making.
- After reaching a decision about a diagnosis, the
clinician - must decide on a plan of treatment and
management for - the particular patient.
- These decisions must take into account the
probability(??) and utility (i,.e., worth or
value) of each possible - outcome of the treatment or management plan
64Decision analysis
- Similarly, the clinician may need to decide
whether to order laboratory tests to confirm a
diagnosis only suggested by the signs and
symptoms elicited during the clinical
examination.
65The ways of clinical thinking??????
- It refers the ways of investigation of disease,
processing the clinical data and making the
decision etc. - It is the basic method in the processes of
clinical diagnosis. - It, however, reflexes the clinicians abilities
of clinical diagnosis - Two basic elements include in the ways of
clinical thinking - clinical practice
- scientifically clinical thinking
66The steps of clinical thinking
- From Anatomical point of view, is there any
- anatomical abnormality?
- From pathological point of view, is there any
- functional changes?
- Based upon the pathophysiological point of view,
- propose the possible mechanisms of
- pathological changes and pathogenesis of the
- disease
- Considering the possible causes of the disease
-
67The steps of clinical thinking
- Considering the possible causes of the disease
- Evaluating the severity of the disease
- Proposing one or two special hypothesis
- Verifying the trueness of the hypothesis
- Considering the differential diagnosis based on
- the special clustering of symptoms
- Focusing on the most possible diagnosis
- Proposing the further examination and treatment
-
68The basic rules of clinical thinking
- The rules of seeking the truth from facts
- ??????
- The rules of monism
- ?????
- The rules of using the prevalence and spectrum
- of the disease to make the diagnostic decision
- ????????????????
69The basic rules of clinical thinking
- The diagnosis of organic diseases is in
priority, - the functional diseases are considered only
those - organic diseases have been ruled out
- The curable diseases are in priority
- The rules of simplifying thinking procedure
70The basic rules of clinical thinking
71The common causes of misdiagnosis
- Incomplete and/or uncertain clinical data
- Rough observation or laboratory errors
- Subjective and groundless conclusion
- Lack of clinical experience
-
-
72Types of clinical diagnosis
- Direct diagnosis
- Excluding diagnosis
- Differential diagnosis
-
73Contents of clinical diagnosis
- Pathogenic diagnosis
- Anatomicopathological diagnosis
- Pathophysilogical diagnosis
- The diagnosis of complications
- The diagnosis of coincide diseases
-