Case: Refuse to duplicate

Case: Refuse to duplicate
Case: Refuse to duplicate
Staff reporter Tan Jia The condition is various, the case is stereotyped. In the 17th academic meeting of professional committee of association's case management of Chinese hospital that was held a few days ago, the copy case persistent ailment that the conferee appears after writing the case in adopting the computer clinically again worries. " the computer applies to clinic, has lightened the burden that a doctor writes the case history in the stereotyped disease case, but following copy case history, has already become the greatest hidden danger that the computer has written the case. " It is said that the case management professional committee's Vice Chairman, horse of associate managing editor of magazine office of " Chinese case " of association of Chinese hospital family is moist, "in the contribution about the quality of the case that the magazine office receives, nearly every one will mention to copy the question of the case. " With the development of computer and network technique, the case electronization of traditional paper, the electronic case systems of patient's medical records become the trend to store, manage, transmit and reappear with the computer. Our country has increasingly many hospitals to begin to write the case with the computer too. Use the computer to write the case, set up the standardized template of case, has helped the case write. Duplication, pasting the repeated work that the function has reduced the doctor too of the computer, the standardized layout form may appear while stopping the tradition more completely handwrittenly " The book from heaven " Case history. , the swift condition of work that the computer has offered the convenience to clinician, but the electronic case records the content and duplicates the question thereupon appearance that melted. Meanwhile, copying the case becomes act that save time to save effort in teacher's eyes of some clinical medicine too. "Different patients of the same kind of disease, its symptom, physical sign describe it is totally unanimous. " Formerly the Deputy Director of medical records Room of BJ Union Hospital horse's family's moist teacher Zeng is from founder Professor Wang XianXing of case of our country, know the case well and record important meanings born the weight of. He says: "The content duplicates, the stereotyped case, has ignored the slight difference record similar to symptom among different patients, can't embody the characteristics and focal points of different cases, has lost the individual characteristic of different cases, have just lost value of clinic, teaching and scientific research. " Except that the content is duplicated, it is quite a few that copy jokes that the case makes a noise out. Male patient case history have the intersection of period and history record, for instance, women patient have prostate to be loose, etc. Even plan the patient that surgery treats mammary gland disease in one hospital, postpone the operation for some reasons, the doctor copied unexpectedly others left hospital and recorded the absurd incident which described the operation situation. "The case history lacks authenticity, dependability, consider in terms of management of the case, this kind of case keeps scientific value more either, know for medical treatment to work to bring the hidden danger yet. " It is said that horse's family is moist. What furthermore the anxiety of personnel training " is worried by people is, totally rely on the working way of the template case to be very unfavorable to the cultivation of medical talents. " Horse moist to say for gather medical history completely, computer make a lot of templates house have, various case history have corresponding form, most content to adopt and play the form of the hook and carry on the record in the square frame. The doctor only needs to fill in according to the form, needing to more consider can finish big case history records such as gathering, physical examination of the medical history,etc.. This causes some young doctors not to pay attention to the case history to write, gather the medical history half-heartedly too, only care about the content listed on the form to fill in. He thinks, ignores the case history and writes or not uses the form case history appropriately, is unfavorable to the cultivation of the young doctor. Xinjiang the intersection of formation of production and construction and hospital the intersection of information center and Cai gaudy to wait for someone, think, use case that function finish of pasting, duplicating etc. too, can't reflect the patient's health status and dynamic change truly, has violated the serious and authenticity principle of the case. Increased the doctor's thinking inertia at the same time, lost the marrow that the case history writes. Of our country the intersection of uncle and salty Professor Wang, founder one of of clinical practice, say, the clinician has two major wealth: First, in charge of the case history to stand up, second, in charge of the library to stand up. A filial piety Qian Professor, everybody of clinical medicine, has written articles to point out, studying clinically should know skillfully first that diagnoses technology too, include medical history adopt and physical diagnosis and regular experiment check, among them the medical history is the most important. If adopt and do in the proper way, the medical history of more than half patient can be offered the valuable diagnosis clue at least. Copy the case, seem to be and save trouble briefly, it was the most valuable wealth of the clinician that was in fact lost. "The case has recorded the patient's symptom, pathology, cause of disease, has reflected the doctor's diagnosis analysis, also reveal the progress of medical science. " The quality of the national case is controlled a Vice Chairman, subsidiary case of Beijing Xuanwu Hospital of Capital University of Medical Sciences of committee and counted head of the department Liu ChunLing and said, machine that format totally play case, reflect clinic, scientific research, profound thinking and content in the teaching while being difficult. Professional case head of the department Liu AiMin of committee's General Board, BJ Union Hospital point out association's case management of Chinese hospital, hit the case and not merely bring out persistent ailment which is copied the case in chance of the complete template, also unfavorable to the training for doctor's clinical thinking, it is more harmful as to the young doctor. The template case writes the way, it is difficult to reflect the doctor's analysis, thinking of diagnosis, it is apt to cause the formatting, fixing and melting of doctor's clinical thinking. Technology should be used Liu AiMin to think, the electronic case system of our country is still at the starting stage at present by me, the respects of designing in the template of the case, constructing systematically etc. all also need further improving and developing. The real electronic case should can realize the information data are not limited by time, space, the doctor can transfer and read at any time; Resources such as case system and electronic information storehouse, library,etc. are connected each other, can consult relevant information and materials according to the need at any time; The intelligent system still can discern to the doctor's clinical diagnosis, proposes warning or consulting etc.. It is reported, our country has not unified the regulation to the template standard of the electronic case at present, self-designed after every template which hospitals uses is communicated with the manufacturer by the hospital. The expert calls upon, the related departments should make the unified norm that the electronic case wrote as soon as possible, define concrete content and way that the case needs filling in. Electronic case medical the intersection of job and inexorable trend of development, but how use advanced technology for work, serve while being clinical appropriately, write every case well, not merely the case manage the topic that workers care about, also every clinician needs to think deeply. Horse's family is moist to propose, in order to finish the case history, long-term serious training is essential. He emphasizes, the clinician, especially young doctor should gather the medical history, check solidly, finish the case history through thinking deeply, pay attention to the basically training of clinical thinking. Also the personage proposes, the hospital should set up the strict authentication procedure to the modification of the electronic case, restrain the behavior of copying the case by rules and regulations. For example can change the color of pasting the script in the electronic case system, in order to distinguish that has not pasted the script; Set up the error-correcting function of prewarning, Remind and warn etc. automatically.


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