【正文】 biopsy to determine the tumor nature。(2)plete removal of the tumor and spread of the periodontal membrane, teeth and gums.(3)a mandibular defect should still depending on the nature of the tumor and then make a decision whether to immediately bone graft, but should be ready to immediately bone graft.(4)preoperative for teeth cleaning and use of yuguo 2013625 8:15operation recordsmake routine local anesthesia on the patient supine, disinfection and shop towels according to maxillofacial surgery pletely and spread of the periodontal membrane, and gums been removed with electricity en peroxide and saline flush was sent to pathological patient went back the ward safetyly at 9:30 , the surgery was te2013626pastoperative recordst ℃, p 80/min, r 23/min, bp 100/ts feel the wound and teeth pain is severe, the wound near swollen gums, jaw was covered with a little ue to analgesic, attention to maintain oral ts require to dischange tomorrow, he would be approved to agree tedischarge recorddate of admission: jun 20st, 2013 date of discharge: jun 26st, 2013 number of days in hospital:6 daysadmitting diagnosis: epulisbrief history patient name :tao lili , age: 48 3 month ago, the patient suddenly found a small mass on lower incisors touching it, she found a mass tendness, she did not get fever ,dizziness, vertigo and patient didn’t pay attention the mass became more and more of system she has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemoptysis, dysuria, hematuria or ankle medical history she has had no previous surgery, accidents or childhood history: she has no history of excessive alcohol or tobacco history she has no family history of cardiovascular, respiratary and gastrointestinal al examination temperature ℃, pulse 80, respirations 20, blood pressure 90/l: plump girl in no apparent : she has no scalp pupils are equally round and reactive to light and cular movements are e are rynx is is no is no cervical or supraclvicular vascular: regular rate and rhythm, normal s1, : clear to auscultation n: bowel sounds present, no ities: there is no cyanosis, clubbing or ogic: cranial nerves iixii are examination is 5/5 in the bilateral upper and lower y, cerebellar and gait are al course the patient was patient was resect the gums tumor and patient was discharged in stable rge diagnosis epulisdischange instrctions: to pay attention to rest, strengthen nutrition, keep the antiinflammatory for three maintain oral review on a regular sis medications needed after patient is to follow up with in one te/ xu yuguo口腔科的門診病歷篇四門診病歷管理制度（一）門診病歷是門診醫(yī)療工作的原始記錄，凡門診病人不論初診復診都應建立門診病歷，現(xiàn)在大多數(shù)醫(yī)院采用的門診病人自管自帶不存檔的做法，是不符合門診管理制度的，一旦發(fā)生醫(yī)療糾紛，有時會增加新的矛盾。為了有利于醫(yī)療科研、觀察病情，凡不建立門診病歷檔案的醫(yī)院也應專門建立?？苹?qū)２〉拈T診病歷保管制度。門診病歷要求用鋼筆書寫，力求通順、完整、簡練、準確，字跡清楚、整潔，不得刪改、剪貼、顛倒，醫(yī)師要簽全名。門診病歷一般項目如病人姓名、性別、年齡、職業(yè)、籍貫、工作單位或家庭地址等內(nèi)容在掛號時就應填寫清楚。醫(yī)師要將病人主訴、現(xiàn)病史、既往史、各種陽性體征和必要的陰性體征、診斷或印象診斷、治療和處理意見等記載于病歷上。每次診察都要填寫曰期，病情急重者還要填寫時間。若要請求他科會診，應將請求目的和本科初步意見填上，若要住院或轉(zhuǎn)診者也要填寫住院原因或轉(zhuǎn)診摘要。（二）嚴格病歷管理，嚴禁任何人涂改、偽造、隱匿、銷毀、搶奪、竊取病歷。（三）除涉及對患者實施醫(yī)療活動的醫(yī)務人員及醫(yī)療服務質(zhì)量監(jiān)控人員外，其他任何機構(gòu)和個人不得擅自查閱患者的病歷。（四）因科研、教學需要查閱病歷的，需經(jīng)患者就診醫(yī)療機構(gòu)的有關(guān)部門同意后查閱。閱后應當立即歸還，不得復印、不得帶走、不得泄漏患者隱私。（五）建立住院病歷編號制度，住院病歷應當標注頁碼。（六）患者住院期間，其住院病歷由所在病區(qū)負責集中、統(tǒng)一保管。（七）住院病歷因醫(yī)療活動或復印、復制等需要帶離病區(qū)時，應當由病區(qū)指定專門人員負責攜帶和保管（但必需按病歷查閱、復印、復制的程序?qū)徟?。（八）住院病歷在病區(qū)期間，如因科室管理不當，而誘發(fā)的醫(yī)療糾紛，其造成的損失由科室承擔，并追究相關(guān)人員的責任?！猠nd—口腔科的門診病歷篇五加強門診病歷質(zhì)量管理 提高門診診療質(zhì)量完成住院病歷寫得好與差，直接反映了一個人的工作態(tài)度及業(yè)務水平，門診病歷往往是多個人的共同成果，由于不連貫性，很難說明某一個醫(yī)師的業(yè)務水平，事實上醫(yī)院對門診業(yè)務的考核也是輕描淡寫，故臨床醫(yī)師不予重視。2．3由于受多種因素影響，門診病歷難以一班書寫完整如輔助檢查的不及時報告，醫(yī)師無法客觀地分析病情及正確地診斷；病人的文化程度不一樣，對疾病認識、表述的深刻及確切程度也不一樣，而門診醫(yī)師沒有過多的時間進行“去粗取精”，因而影響了門診病歷的內(nèi)在質(zhì)量。2．4缺少上級醫(yī)師的監(jiān)督與指導門診診療過程，醫(yī)師與病人是一對一的進行，醫(yī)師對病史的采集及疾病的判斷是一次性完成無法復查，因此，上級醫(yī)師無法監(jiān)督及指導下級醫(yī)師．這與住院病歷的管理截然不同。解決質(zhì)量問題的對策3．1強化質(zhì)量意識，加強質(zhì)量教育強化門診病歷的質(zhì)量意識，使每一個臨床醫(yī)師都認識到門診病歷質(zhì)量的重要性。門診病歷不僅反映病人即時的疾病狀態(tài)及處理情況，也為以后復診提供了資料和依據(jù)；門診病歷，《江蘇衛(wèi)生事業(yè)管理》2000年第2期(第11卷總第54期由病人保管并攜帶，隨著病人的流動而到處展示，展示對象可以是本院不同科室也可以是不同醫(yī)院。這一展示可比較出各科室或各個醫(yī)院的形象及水準。因此，每個臨床醫(yī)師要有較強的質(zhì)量意識。在開展質(zhì)量教育時，要注意發(fā)現(xiàn)問題，做到有的放矢，防止空洞的說教或簡單的處罰，要從思想上糾正輕視門診病歷的傾向。對于新分配到醫(yī)院的住院醫(yī)師，從一開始就要使其形成良好的質(zhì)量意識，上級醫(yī)師要注意樹立榜樣，以身作則，這樣才能教育好下級醫(yī)師。3．2加強考核，責任到人書寫門診病歷要嚴格按照《規(guī)范》的規(guī)定執(zhí)行，檢查中著重加強對門診病歷的考核，責任落實到人。一份不合格門診病歷，問題出在哪個環(huán)節(jié)，該由誰負責就由誰負責，并不因為一份門診病歷由多人書寫而無人負責。門診病歷的質(zhì)量考核應納入個人業(yè)務考核，要具體通報考核中發(fā)現(xiàn)的問題，與獎懲掛鉤。3．3各科室要加強監(jiān)控對于各病區(qū)接診的新病人，接診醫(yī)師除審閱院前病情資料外，同時要注意檢查門診病歷質(zhì)量，對存在明顯質(zhì)量問題或重大缺陷應及時反饋科室。此外在進行三級查房和現(xiàn)住院病歷質(zhì)量檢查時，一并檢查門診病歷質(zhì)量，發(fā)現(xiàn)問題及時指出。3．4質(zhì)量管理委員會要發(fā)揮更有效的作用醫(yī)務科牽頭，院質(zhì)量管理委員會定期組織有關(guān)人員到門診抽查門診病歷質(zhì)量，抽查情況以臨床科室為單位進行分類、匯總，通報評分，抽查結(jié)果作為對科室工作考核的重要內(nèi)容之一，考核結(jié)果與科室獎懲掛鉤，加大考核力度，更有效地發(fā)揮質(zhì)量管理委員會的作用。