【正文】 lpathological results will be also recorded. Others ? The routine medical documents also include summary of preoperation, record of postoperation, record of surgery etc. ? The format is consistent with the record of course of disease. ? Summary of preoperation may emphasize to record the disease condition, reasons of operation, types of operation, the possible plications/situations occurred postoperation, and methods toward to these plications. Others ? Postoperation records should record the condition of surgery, findings during surgery, name of surgery, disease progression during surgery, types of anesthetics, response of anesthetics, treatment advice for post operation etc. ? The record of surgery should be written by surgeon who performed the surgery. Case record of readmission 再次住院病歷 If the patient is readmitted, the number of admission should be noted in the case record. It may also include the following contents: ? If the patient is readmitted for the same disease, it is necessary to record the case summary of the past and the oute of the disease between last discharge and current readmission. Whilst the past history, systemic review and personal history can be further summarized or even be neglected. The new condition should be added. Case record of readmission 再次住院病歷 ? If the patient suffered from a new disease, the case record should be written according to the format of first case record. The past disease can then be categorized into past history or systemic review. Table format of case record Detailed in the text Case record of outpatient 門診病歷 ? It should be written with perspicuity(簡明 ), stressing on the keystone ? The diagnosis can be made after the patient’ s first visit to physician or further consultation with the physician. If the definite diagnosis can’ t be made, the patient can be treated as symptom causes unknown, such as “ abdominal pain causes unknown” , “ fever of unknown origin” . In addition, one or more suspected diagnosis can also be made. Case record of outpatient requirement ? In the department of emergency, the record should include the precise time of consultation. Apart from the present history of illness and most important signs, the vital signs including BP, pulses, breath rates, temperature, conscience, treatment regimes, and course of treatment. If the treatment is failed, ., the patient died, time of death, diagnosis and causes of death should be also included. ? Signature of the physician (hand writing, or stamp) Case record of outpatientcontent ? The cover should be filled with patient’ s name, sex, age, marriage, profession, address, numbers of some important examinations (such as Xray, ECK, CT et al), telephone number, drug allergy ? Day of the service ? Chief plaint ? History of illness (present, associated past history, personal history or family history) ? Physical examination (positive signs and important negative signs) Case record of outpatientcontent ? Laboratory examinations or special examinations ? Preliminary diagnosis ? Treatment (further exams, drugs, time, suggestions) ? Signature Diagnostic reasoning in physical diagnosis ? This is one of the most important topics in the clinical diagnosis, because it considers the methods and concepts of evaluating the signs and symptoms involved in diagnostic reasoning. ? The primary steps in the process involve the following Data collection Data processing Problem list development Data collection 收集資料 ? Data collection is the product of the history and the physical examination. These can be augmented with laboratory and other test results such as blood chemistry profiles, plete blood counts, bacterial cultures, electrocardiograms, and chest xray films. This history, which is the most important element of the database, accounts for more than 70% of the problem list. Data processing 數(shù)據(jù)處理 ? Data processing is the clustering of data (數(shù)據(jù)分組 ) obtained from the history, physical examination, and laboratory and imaging studies. ? ? To fit as many of these clues together into a meaningful pathophysiologic relationship. Hypothesis(假設(shè) ) Impression(印象 ) Primary diagnosis(初步診斷 ) Data processing 數(shù)據(jù)處理 ? For example, suppose the interviewer obtains a history of dyspnea (呼吸困難 ), cough (咳嗽 ), earache (耳痛 ), and hemoptysis (咯血 ). Dyspnea, cough, and hemoptysis can be grouped together as symptoms suggestive of cardiopulmonary disease. Earache does not fit with the other three symptoms and may indicate another problem. Problem list development ? Problem list development results in a summary of the physical, mental, social, and personal conditions affecting the patient’ s health. ? The problem list may contain an actual diagnosis or only a symptom or sign that cannot be cluster