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 organsHead: its size, shape, tenderness, mass, hairEye: 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

• Specialized subject:

such as: surgery

ophthalmology ( 眼科 )

gynecology ( 妇产科 )

Physical examination

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.

• 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 discharge出院记录 ( 出院小结 )

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.

Case record of out-patient--- requirement

• In the department of emergency, the record should

include the precise time of consultation. Apart from the

present history of illness and most important signs, the

vital signs including BP, pulses, breath rates,

temperature, conscience, treatment regimes, and course

of treatment. If the treatment is failed, e.g., the patient

died, time of death, diagnosis and causes of death

should be also included. • Signature of the physician (hand writing, or stamp)

Case record of out-patient---content

• The cover should be filled with patient’s name, sex, age,

marriage, profession, address, numbers of some

important examinations (such as X-ray, ECK, CT et al),

telephone number, drug allergy• Day of the service• Chief complaint• History of illness (present, associated past history,

personal history or family history)• Physical examination (positive signs and important

negative signs)

Case record of out-patient---content

• Laboratory examinations or special examinations• Preliminary diagnosis• Treatment (further exams, drugs, time, suggestions)• Signature

Diagnostic reasoning in physical diagnosis

• This is one of the most important topics in the clinical

diagnosis, because it considers the methods and

concepts of evaluating the signs and symptoms involved

in diagnostic reasoning.

• The primary steps in the process involve the following

Data collection

Data processing

Problem list development

Data collection收集资料

• Data collection is the product of the history and the

physical examination. These can be augmented with

laboratory and other test results such as blood

chemistry profiles, complete blood counts, bacterial

cultures, electrocardiograms, and chest x-ray films.

This history, which is the most important element of the

database, accounts for more than 70% of the problem

list.

Data processing数据处理

• Data processing is the clustering of data ( 数据分组 ) obtained from the history, physical examination, and laboratory and imaging studies.• • To fit as many of these clues together into a meaningful pathophysiologic relationship.

Hypothesis( 假设 )

Impression( 印象 )

Primary diagnosis( 初步诊断 )

Data processing数据处理

• For example, suppose the interviewer obtains a history of dyspnea ( 呼吸困难 ), cough ( 咳嗽 ), earache ( 耳痛 ), and hemoptysis ( 咯血 ).

Dyspnea, cough, and hemoptysis can be grouped together as symptoms suggestive of cardiopulmonary disease.

Earache does not fit with the other three symptoms and may indicate another problem.

Problem list development• Problem list development results in a summary of the

physical, mental, social, and personal conditions

affecting the patient’s health. • The problem list may contain an actual diagnosis or

only a symptom or sign that cannot be clustered with

other bits of data. • The data on which each problem developed is noted. • This list reflects the clinician’s level of understanding of

the patient’s problem, which should be listed in order of

importance.

Problem list development

• The presence of a symptom or sign related to a specific

problem is a pertinent positive. • For example, a history of gout and increased uric acid

level are pertinent positives in a man suffering from

excruciating back pain radiating to his testicle. • This patient may be suffering from renal colic secondary to

a uric acid kidney stone.

Problem list development• The absence of a symptom or sign that, if present, would

be suggestive of a diagnosis is a pertinent negative. • A pertinent negative may be just as important as a

pertinent positive; the fact that a key finding is not present

may help rule out a certain diagnosis.• For example, the absence of tachycardia in a women with

weight loss and a tremor( 震颤 ) makes a diagnosis of

hyperthyroidism less than likely; the presence of

tachycardia would strengthen the diagnosis of

hyperthyroidism

Diagnostic reasoning诊断的论证

• Unfortunately, decisions in medicine can be rarely be

made with 100% certainty

• Probability( 可能性 ) weights the decision

Others

• Sensitivity and Specificity• Likelihood ratio• Ruling in and Ruling out Disease• Positive and Negative Predictive Values

( 阳性预测值和阴性预测值 )• Prevalence

Decision analysis

• Diagnostic reasoning is only the first step in clinical

decision-making. •After reaching a decision about a diagnosis, the clinician

must decide on a plan of treatment and management for

the particular patient. •These decisions must take into account the probability( 概率 ) and utility (i,.e., worth or value) of each possible

outcome of the treatment or management plan

Decision analysis

• Similarly, the clinician may need to decide whether to order laboratory tests to confirm a diagnosis only suggested by the signs and symptoms elicited during the clinical examination.

The ways of clinical thinking临床思维方法

• It refers the ways of investigation of disease, processing the clinical data and making the decision etc. • It is the basic method in the processes of clinical diagnosis.• It, however, reflexes the clinician’s abilities of clinical diagnosis• Two basic elements include in the ways of clinical thinking:

clinical practice

scientifically clinical thinking

The steps of clinical thinking

• From Anatomical point of view, is there any

anatomical abnormality?

• From pathological point of view, is there any

functional changes?

• Based upon the pathophysiological point of view,

propose the possible mechanisms of

pathological changes and pathogenesis of the

disease

• Considering the possible causes of the disease

The steps of clinical thinking

• Considering the possible causes of the disease

• Evaluating the severity of the disease

• Proposing one or two special hypothesis

• Verifying the trueness of the hypothesis

• Considering the differential diagnosis based on

the special clustering of symptoms

• Focusing on the most possible diagnosis

• Proposing the further examination and treatment

The basic rules of clinical thinking

• The rules of seeking the truth from facts

实事求是原则• The rules of monism

一元论原则• The rules of using the prevalence and spectrum

of the disease to make the diagnostic decision

用发病率和疾病谱观点优选诊断原则

The basic rules of clinical thinking

• The diagnosis of organic diseases is in priority,

the functional diseases are considered only those

organic diseases have been ruled out

• The curable diseases are in priority

• The rules of simplifying thinking procedure

The basic rules of clinical thinking

• Evidence based medicine

The common causes of misdiagnosis

• Incomplete and/or uncertain clinical data

• Rough observation or laboratory errors

• Subjective and groundless conclusion

• Lack of clinical experience

Types of clinical diagnosis

• Direct diagnosis

• Excluding diagnosis

• Differential diagnosis

Contents of clinical diagnosis

• Pathogenic diagnosis

• Anatomicopathological diagnosis

• Pathophysilogical diagnosis

• The diagnosis of complications

• The diagnosis of coincide diseases