【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(mén)診病歷篇四門(mén)診病歷管理制度（一）門(mén)診病歷是門(mén)診醫(yī)療工作的原始記錄，凡門(mén)診病人不論初診復(fù)診都應(yīng)建立門(mén)診病歷，現(xiàn)在大多數(shù)醫(yī)院采用的門(mén)診病人自管自帶不存檔的做法，是不符合門(mén)診管理制度的，一旦發(fā)生醫(yī)療糾紛，有時(shí)會(huì)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(mén)診病歷檔案的醫(yī)院也應(yīng)專(zhuān)門(mén)建立專(zhuān)科或?qū)２〉拈T(mén)診病歷保管制度。門(mén)診病歷要求用鋼筆書(shū)寫(xiě)，力求通順、完整、簡(jiǎn)練、準(zhǔn)確，字跡清楚、整潔，不得刪改、剪貼、顛倒，醫(yī)師要簽全名。門(mén)診病歷一般項(xiàng)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(hào)時(shí)就應(yīng)填寫(xiě)清楚。醫(yī)師要將病人主訴、現(xiàn)病史、既往史、各種陽(yáng)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(jiàn)等記載于病歷上。每次診察都要填寫(xiě)曰期，病情急重者還要填寫(xiě)時(shí)間。若要請(qǐng)求他科會(huì)診，應(yīng)將請(qǐng)求目的和本科初步意見(jiàn)填上，若要住院或轉(zhuǎn)診者也要填寫(xiě)住院原因或轉(zhuǎn)診摘要。（二）嚴(yán)格病歷管理，嚴(yán)禁任何人涂改、偽造、隱匿、銷(xiāo)毀、搶奪、竊取病歷。（三）除涉及對(duì)患者實(shí)施醫(yī)療活動(dòng)的醫(yī)務(wù)人員及醫(yī)療服務(wù)質(zhì)量監(jiān)控人員外，其他任何機(jī)構(gòu)和個(gè)人不得擅自查閱患者的病歷。（四）因科研、教學(xué)需要查閱病歷的，需經(jīng)患者就診醫(yī)療機(jī)構(gòu)的有關(guān)部門(mén)同意后查閱。閱后應(yīng)當(dāng)立即歸還，不得復(fù)印、不得帶走、不得泄漏患者隱私。（五）建立住院病歷編號(hào)制度，住院病歷應(yīng)當(dāng)標(biāo)注頁(yè)碼。（六）患者住院期間，其住院病歷由所在病區(qū)負(fù)責(zé)集中、統(tǒng)一保管。（七）住院病歷因醫(yī)療活動(dòng)或復(fù)印、復(fù)制等需要帶離病區(qū)時(shí)，應(yīng)當(dāng)由病區(qū)指定專(zhuān)門(mén)人員負(fù)責(zé)攜帶和保管（但必需按病歷查閱、復(fù)印、復(fù)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(dāng)，而誘發(fā)的醫(yī)療糾紛，其造成的損失由科室承擔(dān)，并追究相關(guān)人員的責(zé)任?！猠nd—口腔科的門(mén)診病歷篇五加強(qiáng)門(mén)診病歷質(zhì)量管理 提高門(mén)診診療質(zhì)量完成住院病歷寫(xiě)得好與差，直接反映了一個(gè)人的工作態(tài)度及業(yè)務(wù)水平，門(mén)診病歷往往是多個(gè)人的共同成果，由于不連貫性，很難說(shuō)明某一個(gè)醫(yī)師的業(yè)務(wù)水平，事實(shí)上醫(yī)院對(duì)門(mén)診業(yè)務(wù)的考核也是輕描淡寫(xiě)，故臨床醫(yī)師不予重視。2．3由于受多種因素影響，門(mén)診病歷難以一班書(shū)寫(xiě)完整如輔助檢查的不及時(shí)報(bào)告，醫(yī)師無(wú)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(duì)疾病認(rèn)識(shí)、表述的深刻及確切程度也不一樣，而門(mén)診醫(yī)師沒(méi)有過(guò)多的時(shí)間進(jìn)行“去粗取精”，因而影響了門(mén)診病歷的內(nèi)在質(zhì)量。2．4缺少上級(jí)醫(yī)師的監(jiān)督與指導(dǎo)門(mén)診診療過(guò)程，醫(yī)師與病人是一對(duì)一的進(jìn)行，醫(yī)師對(duì)病史的采集及疾病的判斷是一次性完成無(wú)法復(fù)查，因此，上級(jí)醫(yī)師無(wú)法監(jiān)督及指導(dǎo)下級(jí)醫(yī)師．這與住院病歷的管理截然不同。解決質(zhì)量問(wèn)題的對(duì)策3．1強(qiáng)化質(zhì)量意識(shí)，加強(qiáng)質(zhì)量教育強(qiáng)化門(mén)診病歷的質(zhì)量意識(shí)，使每一個(gè)臨床醫(yī)師都認(rèn)識(shí)到門(mén)診病歷質(zhì)量的重要性。門(mén)診病歷不僅反映病人即時(shí)的疾病狀態(tài)及處理情況，也為以后復(fù)診提供了資料和依據(jù)；門(mén)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(dòng)而到處展示，展示對(duì)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(gè)醫(yī)院的形象及水準(zhǔn)。因此，每個(gè)臨床醫(yī)師要有較強(qiáng)的質(zhì)量意識(shí)。在開(kāi)展質(zhì)量教育時(shí)，要注意發(fā)現(xiàn)問(wèn)題，做到有的放矢，防止空洞的說(shuō)教或簡(jiǎn)單的處罰，要從思想上糾正輕視門(mén)診病歷的傾向。對(duì)于新分配到醫(yī)院的住院醫(yī)師，從一開(kāi)始就要使其形成良好的質(zhì)量意識(shí)，上級(jí)醫(yī)師要注意樹(shù)立榜樣，以身作則，這樣才能教育好下級(jí)醫(yī)師。3．2加強(qiáng)考核，責(zé)任到人書(shū)寫(xiě)門(mén)診病歷要嚴(yán)格按照《規(guī)范》的規(guī)定執(zhí)行，檢查中著重加強(qiáng)對(duì)門(mén)診病歷的考核，責(zé)任落實(shí)到人。一份不合格門(mén)診病歷，問(wèn)題出在哪個(gè)環(huán)節(jié)，該由誰(shuí)負(fù)責(zé)就由誰(shuí)負(fù)責(zé)，并不因?yàn)橐环蓍T(mén)診病歷由多人書(shū)寫(xiě)而無(wú)人負(fù)責(zé)。門(mén)診病歷的質(zhì)量考核應(yīng)納入個(gè)人業(yè)務(wù)考核，要具體通報(bào)考核中發(fā)現(xiàn)的問(wèn)題，與獎(jiǎng)懲掛鉤。3．3各科室要加強(qiáng)監(jiān)控對(duì)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(shí)要注意檢查門(mén)診病歷質(zhì)量，對(duì)存在明顯質(zhì)量問(wèn)題或重大缺陷應(yīng)及時(shí)反饋科室。此外在進(jìn)行三級(jí)查房和現(xiàn)住院病歷質(zhì)量檢查時(shí)，一并檢查門(mén)診病歷質(zhì)量，發(fā)現(xiàn)問(wèn)題及時(shí)指出。3．4質(zhì)量管理委員會(huì)要發(fā)揮更有效的作用醫(yī)務(wù)科牽頭，院質(zhì)量管理委員會(huì)定期組織有關(guān)人員到門(mén)診抽查門(mén)診病歷質(zhì)量，抽查情況以臨床科室為單位進(jìn)行分類(lèi)、匯總，通報(bào)評(píng)分，抽查結(jié)果作為對(duì)科室工作考核的重要內(nèi)容之一，考核結(jié)果與科室獎(jiǎng)懲掛鉤，加大考核力度，更有效地發(fā)揮質(zhì)量管理委員會(huì)的作用。