Time : 2023-05-11
Medical record paper is an extremely important document in hospitals and clinics to record various medical information that is critical for diagnosis, treatment and care of patients. With the development of technology, there are more and more medical record papers of various types.
1. Medical records
Medical record book is the most basic medical record paper, which is used to record important information such as relevant medical history, examination results and treatment plan discovered by doctors during consultation. Each time a patient visits a doctor, a new medical record book is created that contains all the information relevant to that patient and is kept until the patient needs it.
2. Doctor's order
A doctor's order is a document for a doctor or attending physician to propose specific treatment measures and prescriptions for a patient. This record paper can ensure the consistency of information conveyed by doctors, avoid drug or treatment conflicts, and ensure safe and effective treatment.
3. Nursing record sheet
Nursing record sheet is a recording paper for professional nurses to record and evaluate the nursing process and effect received by patients. This recording method can help medical staff better understand the patient's condition and facilitate the tracking and evaluation of nursing outcomes.
4. Check report
The inspection report is mainly used to record the results of various inspection items, including ECG charts, ultrasound papers, fetal heart rate monitoring papers, etc.
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