View
249
Download
0
Category
Preview:
Citation preview
07
182
.
1.
1 ( )
2.
0804
0804
0803
EMR 0803
0799
(, )( )
0808
( , )
0808
0809
3.
08:30 - 17:30
08:30 - 12:30
183
.
1.
,
, .
.
2.
1)
2)
3)
4) ,
5) ,
6) , ,
7)
8)
3.
(2 ) .
1)
(1) .
.
(2) (,
, /) .
(3) , , , .
, , (),
.( 22, 14)
07
184
(4) .
(5) .
(6)
.
(7)
.
,
.
2)
,
.
(1) 24
(2) ,
(3) 24
(4) 24
(5) 11
(6) 7 , 3
(7)
.
4.
1) (History & Physical Exam.)
24
, .
.
.
185
(1) ( , Chief Complaint, CC)
- .
-
. (remote or recent onset) .
- .
: 1.
2.
- : (; , ) (,
), ( , )
.
(2) (Past History, PHx)
- .
- , ,
- , ; old chart
.
- , ,
(3) (Family History, FHx)
- ( ) , , ,
, .
- .
- .
(4) (Review of System, ROS)
-
.
-
.
-
.
: , , , , , ,
: , , , , , , , , , ,
07
186
, ,
: , , , ,
: , , , ,
: , , , , , , , , , ,
, ,
: , , , , , ,
(): , , , , , , , ,
, ,
: , , , , ,
: , ,
(5) (Physical Examination)
- .
.
.
- , , , , , , ,
.
: , ,
: ,
, , , : , , , , ,
: , , ,
: , ,
: , , , , (heavings) S2, S3
: , , ,
: , , (, , )
() .
() () .
() ( ) .
- 24 .
- , . - .
187
2) (Discharge Summary)
11
.
(1)
. .) ** ; . ; known DM , car accident
. . .* . * .
[,]
* () . .** ;
.
, , , , . . .** Link .
. .
.** .
. * . .
(underlying cause of death) , .*
** .** .
**(
) 0804
.- (digital sign) , . - .- Local .
07
188
(2)
- : (principal diagnosis)
.
-
(complete)
.
.
. , , .
, .
R/O
.
(impression) (temporary Dx)
.
.
.
,
.
(3)
- : ()
()
. .
-
.
.
.(:
.)
189
.( (Resolved conditions or diagnoses),
(statuspost procedures
from previous admission that have no bearing on the current stay)
( (, )
.
.
.)
.
.
(4)
- : .
.
( )
- : .
- :
. .
- .
- .; .
- .
- .
- .
07
190
3) (Admission note)
(1) (admission note) , ,
.
(2) 24
. , .
4) (Progress notes)
(1) ,
.
(2) . ,
.
, , .
(3) , ,
, 1 1
2 .
(4) (brief op note) (
). , , ,
, (, ), , , drain
. ,
.
(5) 1 (Immediate
post op note) .
(6) ; , /// /
/ , , ,
, , , .
.
(7) transfer out note(), transfer in note()
.
, , .
,
191
, .
(8) , , ,
, (expire note)
.
4
.
.
/
- Admission note CC, PI, PHx, ROS, PEx, impression, plan, .
- ( , 3 ) .
- (Brief op note) , , , , .
- (Immediate post op note) .
- transfer out note, transfer in note .
- (expire note) .
- .
5) (Operation Record)
(1) .
( )
.
(2)
, 24
.
(3) .
-
- ,
- (surgeon)
-
- ,
07
192
-
-
- :
-
- , / ,
-
- (regional) .
- (, ) local .
- , , , , , , , , .
- .
6)
(1)
.
(2) / .
(3) / .
7) , , (informed consent)
(1) ,
.
(2)
.
- ()
- ()
- ()
-
- ( )
193
(3) , /
.
-
-
-
-
- .
- .
- CT, MRI .
- CT .
- CT, MRI .
8) (Anesthesia Record)
(1)
- .
- , , .
(2)
- .
- , , , , ,
, , .
- , , , .
- , () , .
9) (Emergency Room Record)
(1)
.
(2) , , ,
07
194
, ,
.
(3) .
-
- ; , , ,
-
- ; ,
, , , ,
-
-
-
-
-
-
-
-
- , , .
- (ER note) . (ER note) .
- , .
10) (Transfer sheet)
(1) , ,
.
,
.
(2) .
- ( 21 5)
195
-
( 21 4)
-
11) EMR
(1)
EMR .
[ ]
1.
- main .
-
.( )
07
196
2.
- EMR .
- .
197
07
198
[() ]
- EMR .
- .
- .
199
(2)
.
.
.
.
.
(3)
EMR
07
200
(4)
:
/
:
/
.
.
.
.
.
(, ()) .
.
.
.
.
201
(5)
-
(, ).
.
& .
-
(, ).
.
& .
( )
07
202
(6)
- .
[ ]
.
(, )
.
.
.
(7)
-
Main, , Text, 4 .
-
.
203
-
(PACS ) .
( ) .
+ .
.
(8)
- :
07
204
.
(), (), , .
/ .
EMR / .
5.
1)
(1)
/
(2)
.
.
EMR Link.
.
( )
.
.
( )
205
15 .
2)
(1)
/
( CoSign )
(2)
.
.
.
07
206
.
( 0799)
(3
) .
( 2012 )
1) .
2)
.
3) /
. 4 30 .
4)
- .(
,
)
- 3 . 1 30
.
- .
[ ]
207
[ ]
- .
- EMR EMR .
.
1) . (, , )
2) .
3) .
07
208
1) . (,,, )
2) .
3) Default .
4) .
[EMR ]
.
1) , .
2) ,
.
3) .
209
[ ]
1) EMR
.
2) .
- .
3) ,
.
[ () ]
1. .
2. EMR .
3. .
07
210
.
( 0809)
1.
1) : ( 21)
2) :
3) : ( 347)
2.
1)
2)
3)
4)
3.
1)
- ?
- ?
- ?
- ?
2)
4.
21
14 .
14( )
, .
211
, 7
. ,
.
, .
.
7
.
,
. ,
.
5.
1) main / .
2)
. (, )
.
3)
.
4) [ ] .
07
212
5) , .
6) ,
. .
(, .)
7)
. (,
.)
213
.
1.
19( )
, .
21( )
.
1
. ,
.
1. ,
2.
3. ,
4. 13, 43, 432 56
5. 5, 11, 113 33 ,
, (),
,
6. 106, 215 218
7. 347
07
214
8. 118
( )
9. 122 14
10. 112
11. 42
40
12. 73
22 23
. ,
.
.
.
22( ) , , ,
( )
.
[231 (
) . 402 ]
215
.
. [ : 2012.4.8] 22
23() 22
(
) .
.
.
61( )
, ,
.
.
1 , ,
, .
1 2 .
[ : 2012.2.5] 61
88() 19, 211, 223, 2734, 2721
2, 334, 351 , 593, 642(823
), 693 821
3
1 . , 19, 211 693
.
07
216
[ : 2012.4.8] 88
882() 20 2 1
.
[ 2009.12.31]
89() 151, 1712(1 2
), 561 4, 571, 5862 1
500 .
90() 1612, 1734, 184, 2135
, 2212, 26, 272, 3313(823
)5( ), 351 , 41,
421, 4834, 772 63
300
.
[ : 2012.4.8] 90
2.
14( ) 22
( )
. , , ,
.
1.
. () ()
. , ,
. ( )
. ()
217
2.
.
. ()
.
. ( )
. ()
.
. ()
.
. ()()()
.
3.
.
.
.
.
15( )
.
1. 5 2. 10
3. 5 4. 10
5. 5 6. 5
7. 5 8. 5
9. (. ) 3
1 (
) .
2
, .
07
218
3.
1. , . 3
2. , . 5 5
3. 3 3 () . 5 5
4. , . 5 5
15( )
.
1.
2.
3.
4.
5.
3 ,
,
6.
.
.
11
.
.
1.
2.
3.
4.
219
16( ) 151
. .
.
71() 5 5
.
1. 1712 1
3
2. 1812, 19, 265 273
3
3. 23
4. 241
5. 592
6. 593 , , ,
--OK
Recommended