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Medical Records and Hospital Regulations

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Medical Records and Hospital Regulations

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Questions and Answers

Highest级别医师每周至少应该查房多少次?

4次

2次 (correct)

3次

1次

对于病危患者，如何书写病程记录？

每天至少1次

每天2次

每周1次

根据病情变化随时 (correct)

患者入院后经相关检查确诊为肝细胞癌，该诊断入院病情为？

情况不明

临床未确定 (correct)

无

有

患者住院治疗期间，由于患者个人原因要求出院，首页离院方式应填写为？

非医嘱离院 Signup and view all the answers

无菌切口/切口愈合化脓，切口等级/愈合类别是？

I/丙 Signup and view all the answers

关于首次病程记录的书写要求，不正确的是？

疾病诊断非常明确时，鉴别诊断可以记录“诊断明确，无需鉴别” Signup and view all the answers

根据规定，术者无需亲自在术前和术后多少小时内查房？

不需要亲自查房 Signup and view all the answers

首次查房记录应当于患者入院多少小时内完成？

8 Signup and view all the answers

患者2021年12月15日入院，2021年12月19日出院，其实际住院天数为？

4 Signup and view all the answers

颅脑损伤患者昏迷时间的填写不正确的是？

颅脑损伤的患者只需填写入院后昏迷时间 Signup and view all the answers

新生儿出生体重是指患儿出生后多少时间第一次称得的重量？

第一小时 Signup and view all the answers

主要手术操作填写顺序正确的是？

按手术操作时间顺序进行填写 Signup and view all the answers

出院诊断名称规范的例子是？

乙状结肠中分化腺癌(T3NOMO) Signup and view all the answers

手术名称填写规范的是？

腹腔镜下胆囊切除术 Signup and view all the answers

出院诊断描述错误的是？

疾病的临终状态可以作为主要诊断 Signup and view all the answers

手术及操作名称要素包括？

部位、术式、入路、疾病性质 Signup and view all the answers