主诉书写的探讨  

Study on Writing of Chief Complaint

作　　者：李国民[1] 吕剑平[1] 陈吉祥[1] 王旭清[1] 徐永中[1] 

机构地区：[1]江苏大学附属医院,镇江市212002

出　　处：《中国病案》2013年第1期38-39,37,共3页Chinese Medical Record

摘　　要：所有医疗记录都是围绕主诉书写的,规范的主诉书写对病案中其他记录书写有重要影响。主诉是患者本次就诊的主要症状或主要原因。书写者可通过病史询问从患者众多症状中挑选出能反应疾病特征的症状作为主诉,并按照症状出现的先后书写。在特殊情况下,将患者就诊的原因作为主诉来书写尤为合理。主诉书写过程中,容易犯语言性错误,加强语言文字功底有助于写好主诉。All medical records are focused on chief complaint in writing. Good writing of medical record for complaints has important implications for other records. The chief complaint is main symptoms or reasons of patients. Writer should choose symptoms as chief complaint, which is from nu- merous symptoms told by patient and can reflex characteristics of the disease. Chief complaint must be written orderly. In special cases, it is more rea- sonable to consider main reason of patient as chief complaint. With the process of writing, it is easy to make language errors. It is useful to enhance lan- maa^e skills for writin~ chief comnlaint.

关 键 词：主诉 病历 书写 语言 

分 类 号：R197.3[医药卫生—卫生事业管理]