现病史书写的探讨  

Investigation on the Writing of History of Present Illness

作　　者：李国民[1] 王旭清[1] 徐永中[1] 吕剑平[1] 陈吉祥[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2期14-15,共2页Chinese Medical Record

摘　　要：现病史是病历记录的核心内容,也是病历质量考核主要内容之一。书写好现病史应该按照现病史书写顺序和疾病发展衍变过程进行书写,不能遗漏每项内容。现病史内容过于简单、杂乱无章等现象是书写中的常见问题,应该给予防范。鉴别资料是现病史书写的难点,鉴别资料含义的明确和鉴别疾病的选择是鉴别资料书写的关键。书写技巧的掌握将有助于书写好现病史。The history of present illness is the core content of medical record and one of the main aspects of medical assessment. To accomplish a good writing history, we should first know the content and without omission, then write it according to the writing basic route and disease development rule. The common problems in writing such as excessively simple, disorderly and unsystematic content should be avoided. In the writing of present illness history, the identification is the difficult point. Definite identification of the implication and the choosen of diseases to be identified are the key to achieve right writing Of differential diagnosis. A good master of writing skill will be helpful to make a good writing of present illness history.

关 键 词：现病史 书写 病历 鉴别诊断 

分 类 号：R197.3[医药卫生—卫生事业管理]