The writing of clinical record

The writing of clinical record Department of Gastroenterology Ren-Ji Hospital Prof. Zhi Hua Ran

A patient’s health record plays many important roles and provides a view of the patient’s health history/status

The basic requirement of clinical records In writing up the history and the physical examination, the examiner should obey the following rules: Record all pertinent (相关的）data, avoid extraneous （无关的）data Use standard format Describe comprehensively, use common terms, avoid nonstandard abbreviations（缩写）

The basic requirement of clinical records Written in an all-round way, all items should be filled, the hand writing should be clear, not scratchy（潦草） or be altered Be objective(客观）, use diagram（图表）when indicated

Types , formats and contents of clinical records

Clinical records during hospitalization The clinical records should be written during hospitalization It includes: Case record First record of admission Record of the course of disease Record of consultation Record for transferring to new department Record of discharge Record of death Record of surgery

Case record The case record should be written systemically and completely within 24 h by intern

Formats and contents of case record Case record Name Sex Age Marital status Nation Profession Native place Current address Data of admission Data of case record Source Reliability

Chief compliant History of present illness Past illness Systemic review Personal history Marriage Reproductive and Gynecologic history Family history

Physical examination Temperature Pulse Respiratory Blood Pressure General appearance: development, nutrition (well, moderate, poor) facial expression (acute or chronic, suffering expression, anxiety, fear, calm) position, gait mental status: alert, obscure（不清楚的）, lethargy（昏睡）, coma cooperative

Physical examination Skin and mucous: color (reddish, paler, cyanosis, yellowish, pigmentation) swelling, moisture, elasticity, bleeding, rashes, subcutaneous nodular, spider angioma（蜘蛛痣）, ulceration, scar. The location, size and shape should be recorded. Lymph note: systemic or localized lymph notes (submaxillary, 下颚；posterior auricular, 耳后的；neck, armpit, 腋窝；groin，腹股沟). Its size, number, tenderness, hardness, mobility, fistula（漏管）, scar etc.

Physical examination Head and organs Head: its size, shape, tenderness, mass, hair Eye: eyebrow（眉毛）, eyelash（睫毛）, eyelid,（眼睑） eyeball (protrude/突出, sunk/凹陷, movement, tremble/震动, strabismus/斜视), conjunctiva（结膜）, sclera(巩膜）, cornea/角膜(size, shape, symmetry, light reflex, near reflex). Ear: discharge, hearing, mastoid（乳突）. Nose: abnormality; tenderness of maxillary sinus（上颌窦）, ethmoid sinus（筛窦）, frontal sinus（额窦）; exudation（分泌）, bleeding.

Physical examination Oral cavity: odor, lips (color, swelling, ulceration, herpes simplex, pigmentation); teeth; gingival（齿龈）; tongue (mass, ulceration，coating of the tongue, mucus (rash, bleeding, ulceration); tonsils（扁桃腺）; pharynx（咽）etc. Neck: symmetry; texture (slightly flexed and cradled in the examiner’s hands); thyroid gland (size, hardness, tenderness, nodular, tremble, murmur); superficial venous distention; the position of the trachea.

Physical examination Chest: configuration; symmetry; local protrude; tenderness; respiratory rate and pattern; abnormal pulsate（异常搏动）; breast (size, mass); venous distention

Physical examination Lung: Inspection: respiratory movement; interspace of ribs; Palpation: the extent of chest excursion（移动）; vocal fremitus （语颤）; Speech creates vibrations that can be heard when one listens to the chest and lungs. These vibrations are termed vocal fremitus. When one palpates the chest wall while an individual is speaking, these vibrations can be felt and are termed tactile fremitus（触觉语颤）. Pleura friction（胸膜摩擦音）; subcutaneous crepitus（捻发音）.

Physical examination Percussion: resonance tympany hyperresonance dullness flatness diaphragmatic movement Auscultation: breath sounds tracheal bronchial bronchovesicular vesicular

Physical examination Heart: Inspection: apical impulse, or its location, area and intensity Palpation: assessing point of maximum impulse, thrills, fremitus Percussion: percuss the heart’s borders, the relative dullness or absolute dullness borders Auscultation: the heart rates, rhythm, heart sounds, murmur（杂音）, abnormalities of the S1, S2, splitting of S2, systolic clicks, diastolic opening snaps, vocal fremitus, premature beats（早搏）

Physical examination Radial artery (桡动脉): pulse rate, rhythm (regular or irregular), pulse deficit（脉搏短促）. The pulse may be described as normal, diminished, increased, or double-peaked. Peripheral vascular signs: capillary strike signs, bruits（杂音）, abnormal artery movement.

Abdomen Inspection: symmetry, size, abdominal distention, pitting (concave abdomen), respiratory movement, skin lesion, pigmentation, surgical scar, umbilicus, hernia（疝）, body hair, venous distention and direction of blood flow, peristaltic waves（蠕动波); ecchymoses (淤斑) Palpation: the tenderness of abdominal wall, rebound tenderness, mass (location, size, shape, texture, tenderness, motion, mobility)

Abdomen Liver: size, character, surface, edge, tenderness, motion. Gallbladder: size, shape, tenderness Spleen: size, character, tenderness, surface, edge Kidney: size, shape, character, tenderness, mobility Bladder: distention (膨胀) costovertebral（肋椎的) angle tenderness

Abdomen Percussion: liver dullness borders, hepatic tenderness over the right upper quadrant, shifting dullness (移动性浊音) Auscultation: bowel sounds(肠鸣音), vascular bruits Anus and rectum: anal fissure (肛裂) anal fistula (肛瘘 ) pile(痔) digital rectal examination(肛指检查)

Genitalia Male: pubes(阴毛), penis(阴茎), glans(龟头) scrotum (阴囊), testicles (睾丸), epididymis(副睾), Female: External: pubes, vagina(阴道), urethral meatus(尿道口), hymen(处女膜), labia minora (小阴唇), labia majora (大阴唇), clitoris(阴蒂) Internal: ovary(卵巢), uterus(子宫), fallopian tube (输卵管)

Physical examination Spine: tenderness, abnormal spinal extension/rotation, lateral deviation Extremities: deformity, venous distention, stiffness, limitation of motion, joint, strength

Physical examination Nervous system: biceps tendon reflex (二头肌反射) triceps tendon reflex (三头肌反射) patellar tendon reflex (膝腱反射) Achilles tendon reflex (跟腱反射) abdominal superficial reflex (腹部反射) cremasteric superficial reflex(提睾反射) test for abnormal reflexes: babinski sign, chaddock’s sign, hoffmann’s sign

Physical examination Specialized subject: such as: surgery ophthalmology (眼科) gynecology (妇产科)

Laboratory and other special examinations Laboratory tests: record all those data that are associated with diagnosis, including three routing tests and other laboratory tests 24 h after admission. Special exam: gastroscopy, barium enema, X-ray etc.

Summary Combining with the case history, physical examination and laboratory data, propose the evidences of diagnosis, and finally set up the diagnosis Preliminary diagnosis Signature or stamps

Common medical documents Record of admission Record of the course of disease Record of consultation Record for transferring to new department Record of discharge Record of death Others

Record of admission入院录 The record of admission is the abstract form of full case record. The key points should be emphasized, and it should be written concisely(简明) or compendiously(简要), and should be finished with 24 h after admission by resident The chief complain and present illness are written in the same form as full case record, the others could be written in the short form, without the abstract.

The format and content of record of admission General information of the patient Chief complaint Present history of illness Past history in summary Physical examination Vital signs General appearance and systemic organs Laboratory tests Preliminary diagnosis Signature

Record of the course of disease病程记录 It records the progression and treatment of the whole courses of patient’s disease during one’s admission. It should be recorded with trueness, promptly, with prospective analysis. It actually reflects the quality of the medical treatment. It can be written once a day according to the changes of the disease. For those severe cases, it should be written several times per day. For those patients with mild illness, however, it could be written every 2~3 day.

The content of records are generally including The patient’s complains (about his/her discomfort, moods, physiological status, food, sleep, relieve oneself, those can be further selected according to the need for the progression of the disease. The changes of disease, including signs and symptoms, or any new discovery, the results of various laboratory or other adjuvant examinations, the analysis, evaluations, or remarks on those data.

The content of records are generally including The records of various manipulations, such as plural puncture, abdominal puncture, lumber puncture, endoscopy, cardiac catheter exam, various radiography. Reinforce or amend the clinical diagnosis, amend the evidences for the diagnosis. The opinion of senior doctor about the diagnosis and differential diagnosis. The treatment, drug use and its efficacy or side effects. Opinion of consultation of other department.

The content of records are generally including Information from patient’s relatives (their hope, desire, and reflection; the information that the doctor induced to the patient’s relatives Monthly brief phase summary Time of record and signature

The first record of the course of disease 首次病程录 The first record of the course of the disease should be recorded at the same day as admission, its content and format are different from that of other record of course of the disease, including ① patient’s name, sex, age, chief complain, prominent signs and symptoms, results of those adjuvant examination, that are highly summarized and emphasizing the key profiles.

The first record of the course of disease首次病程录 ② Propose the preliminary diagnosis, differential diagnosis and their evidences, based upon above data. ③ Propose some other special examinations in order to further confirm the diagnosis ④ Propose the treatment and diagnostic planning according to the actual situation of patients’ illness on admission

Record of consultation 会诊记录 If the patient presents other system disease, or symptoms difficult to diagnose, other specialist may be invited for consultation. In general, the consultant opinion will be written in consultant sheet. The consultant opinion includes brief description of case record, specialized examinations, the analysis and diagnosis of the disease, propose his opinion for further more precise examinations.

Record of consultation If the opinions are collectively, record all those doctors participating the consultation, their analysis, examination, and treatment.

Record for transferring to new department转科记录 During the periods of hospitalization, the patient may present symptoms of other systems (department). With the approval of doctor of other department, the patient can now be transferred to the new department. It can be written in the record of the course of disease’s sheet. The content may include the major cause of disease, treatment, the reasons for transferring, the precaution notes etc.

Record for transferring to new department If the patient is transferred from other department, resident should write the record of transferring, the content of the record is similar to that of record of admission.

Record of discharge出院记录(出院小结) When the patient is going to be discharged, the record of discharge should be written, and give to the patient on the data of discharge. The content includes: Name, sex, age, diagnosis on admission, data of admission, diagnosis on discharge, data of discharge, days of hospitalization. Various numbers of special examination (number of hospitalization, number of X-ray, CT, pathology, EKG etc.

Record of discharge出院记录(出院小结) Briefly introduce the reason of admission, present illness, the data of major examinations, the progression and treatment of the disease during hospitalization. The condition of patient on discharge, including signs and symptoms, results of major examination and treatment (recover, improve, no effect, exacerbate, complication). The treatment advice on discharge, notes for precaution

Record of death死亡记录 The record of death should be recorded immediately after death of patient. The content and format of death record are similar to that of discharge record. It includes case summary, hospitalization, diagnosis and treatment, the causes for disease’s progression, the rescue course, time of death, causes of death, and final diagnosis.

Record of death死亡记录 For all death patients, particularly those cases the diagnosis are uncertain, one should persuade the relatives of death patient to perform the autopsy, the anatomicalpathological results will be also recorded.

Others The routine medical documents also include summary of preoperation, record of post-operation, record of surgery etc. The format is consistent with the record of course of disease. Summary of pre-operation may emphasize to record the disease condition, reasons of operation, types of operation, the possible complications/situations occurred post-operation, and methods toward to these complications.

Others Post-operation records should record the condition of surgery, findings during surgery, name of surgery, disease progression during surgery, types of anesthetics, response of anesthetics, treatment advice for post- operation etc. The record of surgery should be written by surgeon who performed the surgery.

Case record of readmission 再次住院病历 If the patient is readmitted, the number of admission should be noted in the case record. It may also include the following contents: If the patient is readmitted for the same disease, it is necessary to record the case summary of the past and the outcome of the disease between last discharge and current readmission. Whilst the past history, systemic review and personal history can be further summarized or even be neglected. The new condition should be added.

Case record of readmission再次住院病历 If the patient suffered from a new disease, the case record should be written according to the format of first case record. The past disease can then be categorized into past history or systemic review.

Table format of case record Detailed in the text

Case record of out-patient 门诊病历 It should be written with perspicuity(简明), stressing on the keystone The diagnosis can be made after the patient’s first visit to physician or further consultation with the physician. If the definite diagnosis can’t be made, the patient can be treated as symptom causes unknown, such as “abdominal pain causes unknown”, “fever of unknown origin”. In addition, one or more suspected diagnosis can also be made.

The writing of clinical record