This is how parallel medical records help patients
2023-02-07
The picture shows Zhao Bin at work. Each doctor in Beijing Jishuitan Hospital must face one thing in clinical work - writing medical records. Medical record is a record of a series of medical activities of each patient from the occurrence, development and outcome of the disease to the auxiliary examination, diagnosis and treatment plan. Today, narrative medicine adds a new member to the family of medical records - "parallel medical records". Medical records should also be "reliable, reliable and elegant". Beijing Union Medical College Hospital has "three treasures": medical records, professors and libraries. Among them, the first treasure "medical record" is the medical record, which is not only the presentation of the real scene of the patient's illness process, but also the concrete manifestation of the doctor's thinking, and also the evidence of future clinical experience and scientific research. Not every doctor can write a good medical record. When doctors first write medical records, they often have three worries: the first worry is "fear", that is, they don't know what to ask and how to ask when they see the patient, they don't know what to ask, they don't talk after they say it, and they are hesitant; The second problem is "logic", that is, we can't connect the content of the question with the patient's statement. The written medical record is not only confused by others, but also unknown to ourselves; The third worry is "insipid". The medical records are the same, without focus or characteristics. Even if you make a mistake, it is difficult to be found. Yan Fu said that there are three difficulties in translation: faithfulness, expressiveness and elegance. The medical record should also be reliable, accurate and elegant. A qualified medical record is the historical data of a patient's illness, from which we can see the patient's every bit in the disease, read the clinical thinking of the doctor who wrote the medical record, and also make full preparation for the clinical evidence needed for future research and review. Of course, the accurate and smooth recording of symptoms, examination, treatment and other information can meet the standard of "faithfulness" and "reaching", which is the minimum standard as a common clinical medical record. So how can "elegance" be realized? There is a fixed rule for doctors to be accepted into the empathy circle of patients to format the medical record. The order cannot be reversed, the case can not be extended, and do not guess. As long as the disease is explained clearly, explained clearly, and the clinical diagnosis is logically launched, the mission is completed. When writing a formatted medical record, the doctor is objective, calm, and has a certain template, and should not break through at will. The chief complaint, current medical history, past history and personal history can not be used subjectively in terms of the number of words, order, wording, or description of symptoms, which reflects the doctor's careful thinking. Parallel medical records focus on doctors' attention to patients' sufferings. Through doctors' empathy, patients' experiences and feelings are reproduced, and then doctors are accepted into patients' empathy circle. Doctors and patients work together to fight the disease. There is emotional injection in the parallel medical record, which represents the collision between doctors and patients, and embodies the humanistic value of medicine. There is no fixed mode for parallel medical records. In addition to basic medical skills, it is also necessary to have humanistic tolerance and integrate human emotions when writing. The purpose of parallel medical records is the same as that of narrative medicine - by narrating the disease, the patient, disease and pain are linked, the biological world of disease and the life world of people are linked, and the disease is explained
Edit：Ying Ying Responsible editor：Jia Jia
Source：People.cn
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