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某院抽组的医疗队在赴非收治埃博拉病毒病烈性传染病患者时,面对病史采集、病历书写、病历传输等方面的新情况,医疗队对当地配属医务人员进行了病史采集和病历书写培训,制定了入院首次记录和日常查房病程记录的表格式病历模板,规范了病历书写内容和形式,并利用当地现有条件实现了病历从隔离区到清洁区的有效传输,对后期临床病例的统计分析和临床科研提供了基础素材,以上问题的逐步解决为今后国内外收治烈性传染病患者时如何进一步做好病历书写和管理积累了一定经验。
Medical teams drawn by a hospital visited non-Eritreae patients with potent infectious diseases in the past few years. Faced with the new situation of medical history collection, medical record writing and medical records transmission, medical teams collected medical records of local affiliated medical staffs, Medical records writing training, developed for the first time admission records and routine ward records of the form of medical record template, standardized medical records written form and content, and use of existing local conditions to achieve the effective transfer of medical records from the isolation zone to the clean area, the late Clinical cases of statistical analysis and clinical research provides the basic material, the gradual resolution of the above problems for future treatment of patients with potent infectious diseases at home and abroad how to do a better record and management of medical records have accumulated some experience.