The writing of clinical record

1
The writing of clinical record
Department of Gastroenterology Ren-Ji Hospital
Prof. Zhi Hua Ran
2

• A patients health record plays many important
  roles and provides a view of the patients health
  history/status

3
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 (???) data, avoid
  extraneous (???)data
• Use standard format
• Describe comprehensively, use common terms,
  avoid
• nonstandard abbreviations(??)

4
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(??)
• or be altered
• Be objective(??), use diagram(??) when
• indicated

5
Types , formats and contents of clinical records
6
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

7
Case record

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

8
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

9

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

10
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(????),
• 
  lethargy(??), coma
• cooperative

11
Physical examination

• Skin and mucous
• color (reddish, paler, cyanosis,
  yellowish, pigmentation)
• swelling, moisture, elasticity,
  bleeding, rashes, subcutaneous
• nodular, spider angioma(???),
  ulceration, scar.
• The location, size and shape should be
  recorded.
• Lymph note
• systemic or localized lymph notes
• (submaxillary, ??posterior auricular,
  ???neck,
• armpit, ??groin,???).
• Its size, number, tenderness, hardness,
  mobility, fistula(??),
• scar etc.

12
Physical examination

• Head and organs
• Head its size, shape, tenderness, mass, hair
• Eye eyebrow(??), eyelash(??), eyelid,(??)
• eyeball (protrude/??, sunk/??,
  movement, tremble/??,
• strabismus/??),
• conjunctiva(??), sclera(??),
• cornea/?? (size, shape, symmetry,
  light reflex, near reflex).
• Ear discharge, hearing, mastoid(??).
• Nose abnormality tenderness of maxillary
  sinus(???), ethmoid sinus(??), frontal sinus(??)
  exudation(??), bleeding.

13
Physical examination

• Oral cavity odor, lips (color, swelling,
  ulceration, herpes simplex,
• pigmentation) teeth
  gingival(??)
• tongue (mass,
  ulceration,coating of the tongue,
• mucus (rash, bleeding,
  ulceration)
• tonsils(???) pharynx(?)
  etc.
• Neck symmetry texture (slightly
  flexed and cradled in the
• examiners hands) thyroid
  gland (size, hardness,
• tenderness, nodular,
  tremble, murmur) superficial venous
• distention the position of
  the trachea.

14
Physical examination

• Chest configuration symmetry local protrude
  tenderness
• respiratory rate and pattern
• abnormal pulsate(????)
• breast (size, mass) venous
  distention

15
Physical examination

• Lung
• Inspection respiratory movement
  interspace of ribs
• Palpation the extent of chest
  excursion(??) vocal fremitus
• (??)
• 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(????).
• Pleura friction(?????)
• subcutaneous
  crepitus(???).

16
Physical examination

• Percussion resonance tympany
• hyperresonance
  dullness
• flatness
• diaphragmatic movement
• Auscultation breath sounds
• tracheal
• bronchial
• bronchovesicular
• vesicular

17
Physical examination

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

18
Physical examination

• Radial artery (???)
• pulse rate, rhythm
  (regular or irregular),
• pulse deficit(????).
• The pulse may be described as normal,
  diminished,
• increased, or double-peaked.
• Peripheral vascular signs capillary strike
  signs,
• 
  bruits(??),
• 
  abnormal artery movement.

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Abdomen

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

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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 (??)
• costovertebral(???) angle
  tenderness

21
Abdomen

• Percussion liver dullness borders, hepatic
  tenderness over
• the right upper quadrant,
• shifting dullness (?????)
• Auscultation bowel sounds(???), vascular
  bruits
• Anus and rectum anal fissure (??)
• anal fistula
  (?? )
• pile(?)
• digital rectal
  examination(????)

22
Genitalia

• Male pubes(??), penis(??), glans(??)
• scrotum (??), testicles (??),
  epididymis(??),
• Female
• External
• pubes, vagina(??), urethral
  meatus(???),
• hymen(???), labia minora (???),
• labia majora (???), clitoris(??)
• Internal ovary(??), uterus(??),
• fallopian tube (???)

23
Physical examination

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

24
Physical examination

• Nervous system
• biceps tendon reflex (?????)
• triceps tendon reflex (?????)
• patellar tendon reflex (????)
• Achilles tendon reflex (????)
• abdominal superficial reflex (????)
• cremasteric superficial reflex(????)
• test for abnormal reflexes
• babinski sign, chaddocks sign,
  hoffmanns sign

25
Physical examination

• Specialized subject
• such as surgery
• 
  ophthalmology (??)
• gynecology
  (???)

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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.

27
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

28
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

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Record of admission???

• The record of admission is the abstract form of
  full case
• record. The key points should be emphasized,
  and it
• should be written concisely(??) or
  compendiously(??), 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.

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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

31
Record of the course of disease????

• It records the progression and treatment of the
  whole
• courses of patients disease during ones
  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
  23 day.

32
The content of records are generally including

• The patients 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.

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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.

34
The content of records are generally including

• Information from patients relatives (their
  hope, desire,
• and reflection the information that the doctor
  induced to
• the patients relatives
• Monthly brief phase summary
• Time of record and signature

35
The first record of the course of disease ?????

• 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
• ? patients name, sex, age, chief complain,
  prominent
• signs and symptoms, results of those
  adjuvant
• examination, that are highly summarized and
• emphasizing the key profiles.

36
The first record of the course of disease?????

• ? Propose the preliminary diagnosis, differential
  
• diagnosis and their evidences, based upon
  above data.
• ? Propose some other special examinations in
  order to
• further confirm the diagnosis
• ? Propose the treatment and diagnostic planning
• according to the actual situation of
  patients illness on
• admission

37
Record of consultation ????

• 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.

38
Record of consultation

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

39
Record for transferring to new department????

• 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
  diseases
• sheet.
• The content may include the major cause of
  disease,
• treatment, the reasons for transferring, the
  precaution
• notes etc.

40
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.

41
Record of discharge????(????)

• 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.

42
Record of discharge????(????)

• 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

43
Record of death????

• 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 diseases progression, the
  rescue course,
• time of death, causes of death, and final
  diagnosis.

44
Record of death????

• 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.

45
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.

46
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.

47
Case record of readmission ??????

• 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.

48
Case record of readmission??????

• 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.

49
Table format of case record

• Detailed in the text

50
Case record of out-patient ????

• It should be written with perspicuity(??),
  stressing on the keystone
• The diagnosis can be made after the patients
  first visit
• to physician or further consultation with the
  physician.
• If the definite diagnosis cant 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.

51
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)

52
Case record of out-patient---content

• The cover should be filled with patients 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)

53
Case record of out-patient---content

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

54
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

55
Data collection????

• 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.

56
Data processing????

• Data processing is the clustering of data (????)
  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(??)
• Impression(??)
• Primary diagnosis(????)

57
Data processing????

• For example, suppose the interviewer obtains a
  history
• of dyspnea (????), cough (??), earache (??),
  and
• hemoptysis (??).
• 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.

58
Problem list development

• Problem list development results in a summary of
  the
• physical, mental, social, and personal
  conditions
• affecting the patients 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 clinicians level of
  understanding of
• the patients problem, which should be listed
  in order of
• importance.

59
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.

60
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(??) makes a diagnosis
  of
• hyperthyroidism less than likely the presence
  of
• tachycardia would strengthen the diagnosis of
• hyperthyroidism

61
Diagnostic reasoning?????

• Unfortunately, decisions in medicine can be
  rarely be
• made with 100 certainty
• Probability(???) weights the decision

62
Others

• Sensitivity and Specificity
• Likelihood ratio
• Ruling in and Ruling out Disease
• Positive and Negative Predictive Values
• (???????????)
• Prevalence

63
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(??) and utility (i,.e., worth or
  value) of each possible
• outcome of the treatment or management plan

64
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.

65
The ways of clinical thinking??????

• 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 clinicians abilities
  of clinical diagnosis
• Two basic elements include in the ways of
  clinical thinking
• clinical practice
• scientifically clinical thinking

66
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

67
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

68
The basic rules of clinical thinking

• The rules of seeking the truth from facts
• ??????
• The rules of monism
• ?????
• The rules of using the prevalence and spectrum
• of the disease to make the diagnostic decision
• ????????????????

69
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

70
The basic rules of clinical thinking

• Evidence based medicine

71
The common causes of misdiagnosis

• Incomplete and/or uncertain clinical data
• Rough observation or laboratory errors
• Subjective and groundless conclusion
• Lack of clinical experience

72
Types of clinical diagnosis

• Direct diagnosis
• Excluding diagnosis
• Differential diagnosis

73
Contents of clinical diagnosis

• Pathogenic diagnosis
• Anatomicopathological diagnosis
• Pathophysilogical diagnosis
• The diagnosis of complications
• The diagnosis of coincide diseases