Re: [問題] 請問病歷哪種寫法上法院比較慘?

作者: proudC (call me 酷哥)   2018-08-14 20:34:07
目前看起來似乎是簡單寫樂勝
GAN,那當初clerk在學寫病歷是87嗎?
換個情境好了
如果還是偏向簡單寫以後我就真的要改習慣了
病人因胸痛來急診,EKG 和心肌酵素都正常
1.Atypical chest pain
處方 : propanolol 10 mg TID
aspirin 100 mg QD
CV OPD 3 天後
Inform risk of sudden death
2.Anterior chest pain for 2 days, mild, stabbing-like, intermittent,
last seconds to minutes, without radiating. sometimes onset when watching TV,
minimally aggravated by exertional activity,
more frequently in recent days, feeling more stressful recently
處方 與上面一樣,也約回診也告知 sudden death風險
結果病人回去隔天就 OHCA
簡單寫還會樂勝嗎 ? 還是在鬼島都該死 ?
作者: whitezealman   2018-08-14 22:35:00
理論上是簡單樂勝 多寫多錯 但重要的sign跟處置要帶到 重點是要記錄事實 以及減少上法院時被挑剔的機率

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