病程记录

转科记录包括转出记录和转入记录，是病程记录的一部分。

The transferred record , including transferred-out record and transferred-in record , is a part of progress note .

对每个“活动”的问题都应在病程记录中记录。

A progress note should be written for each " active " problem .

当书写病程记录时，遵循SOAP的格式会比较有帮助。

When writing progress notes , it 's helpful to follow the SOAP format .

主诊医生应定期检查病程记录以确保按时完成。

The attending physician should review these notes regularly to ensure compliance .

应在两个不同的病程记录里记录这些资料来说明每个问题。

These data should all be recorded in two separate progress notes addressing each specific problem .

每天在病历中详细记录的病程记录对于病人的评估来说非常有价值。

Detailed daily progress notes recorded in the patient 's medical record are valuable for patient assessment .

主诊医生应负起责任，督促低年资医生每天完成病程记录。

It is the attending physician 's responsibility to ensure that his junior staff record progress notes daily .

遇到危重病人时，同一天里可能要记好几次病程记录。

Occasionally with critically ill patients , it will be necessary to record several progress notes during the same day .

结果住院志、病程记录、各种辅助报告单存在亟待重视、解决的书写缺陷；

Rusults There are writing deficit in hospitalization record , progress note , various kinds of assist information paper and various consent book .

最近有位医学生告诉我有些医学生在忙碌地补写2周前已经出院病人的病程记录。

Recently , a medical student informed me that she observed a group of medical students busily writing progress notes in charts of patients that had been previously discharged two weeks prior .

结果一体化记录加强了医护合作，减少了医护记录不一致的错误，病程记录更系统、更完整、更合理。

Results The synthesis of medical and nursing records reduced the errors of the discordance in medical and nursing records , and the records of illness course became more systematic , integrated and reasonable .

方法通过医院病人信息查询系统，对全院电子病案质量进行实时监控分析，了解首次病程记录、入院病历、三级检诊完成时限。

Methods Monitoring and analyzing the quality of the electronic medical records through the realtime controlling system to know the first disease process , the admission record and time limit of examinations and diagnosis .

方法对某医院2002～2004年住院病案首页、病历、病程记录、其它内容四大方面的病案质量试用模糊数学的原理、方法进行评判。

Methods By using the principle and method of vague mathematics , we judged the qualities from the front sheet , clinical records , progress notes and other contents in the medical record during 2002 to 2004 in a hospital .