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现病史是病历记录的核心部分,也是错误最常发生的部分。医学生由于经验不足,所写的病历抓不住现病史的书写要点,经常出现现病史与主诉脱节;现病史全部抄录门诊病历或外院病历记载;发病诱因记述不当或过简;主要症状描述不明确或不全;病情发展演变及院外治疗经过描述不详;伴随症状和鉴别诊断描述不系统或缺乏描述;一般情况书写错误或不全等错误。希望通过对现病史的书写要点、注意事项的介绍,以及对常见错误的分析,能对医学生起到举一反三的作用。
The current medical history is the core part of the medical records, but also the most common part of the error. Medical students due to lack of experience, written medical records can not grasp the history of the current writing points, the current history of illness and the main complaint is often out of touch; history of all medical records copied outpatient or outside the hospital records; incidence of incentives described improper or too brief; Clear or incomplete; the evolution of the disease and hospital treatment after the description is not known; accompanied by symptoms and differential diagnosis description is not systematic or lack of description; general situation wrong or incomplete error. Hope that through the history of the current writing points, the introduction of precautions, as well as the analysis of common mistakes, medical students can play a role to play a positive role.