晚期恶性肿瘤病案的书写要点

摘要

Patients with late malignant tumor in a critical condition, on the verge of death, its main reason for the medical record quality is not high is the complex disease which difficult to comprehensive overview, no special treatment make treatment method is not clear, many medical documents become a mere formality. To improve the quality of the medical record writing, discuss the key points of writing, puts forward the classification method of comprehensive evaluation based on subjective and objective condition, including rehydration plan, diet guidance and ladder analgesic solution treatment plan, special treatment prior to the discipline of complete multidisciplinary consultation and signed with individual analysis of informed consent, death discussion focuses on death and disease development process analysis and other methods. Meet the requirements of logic, rigour, the academic, pay attention to quantitative numerical, specific and personalized, can greatly reduce the omission, enrich medical record specific, give attention to both form and quality.%晚期恶性肿瘤患者的病案质量不高的主要原因为病情复杂不易全面概括，无特殊治疗使治疗方案条理不清，医疗文书较多但内容流于形式。为提高此类病案书写质量，探讨其书写要点，提出在分级法全面评估主客观病情基础上，制定包含补液计划、饮食指导和阶梯镇痛方案的治疗计划，特殊治疗前进行学科齐备的多学科会诊并签署具有个体化分析的知情同意书，死亡讨论侧重猝死原因和疾病发生发展过程分析等方法，书写中以逻辑性、严谨性、学术性为要求，注重数值量化、具体化、个性化，可以较大程度减少疏漏，使病案充实具体，兼顾形式与质量。