The core system of hospital is the key standard system to ensure the medical quality of hospital, standardize the diagnosis and treatment behavior and put an end to medical accidents. It is also a working rule that medical staff must abide by in normal medical activities. The first-visit doctor or department is the first-visit doctor and the first-visit department, and the first-visit doctor is responsible for the examination, diagnosis, treatment, rescue, transfer and major change of patients.
The first-time physician must inquire about the medical history in detail, carry out physical examination, necessary auxiliary examination and treatment, and carefully record the medical records. Patients with definite diagnosis should be treated actively or put forward treatment suggestions, while patients with unclear diagnosis should be treated symptomatically, and the superior doctors or relevant departments should be consulted in time.
Ward round content
Residents are required to focus on critically ill, difficult, pending, newly admitted to hospital, patients after surgery, and general patients in rounds. Check the inspection report, analyze the inspection results, and put forward suggestions for further inspection or treatment. Check the implementation of doctor's orders on the same day, and give the necessary temporary doctor's orders and special inspection doctor's orders the next morning. Ask and check the patient's diet, and actively seek the patient's opinions on medical care and diet.
Attending physician's rounds require systematic rounds of patients in charge. Especially for patients who are newly admitted to the hospital, are in critical condition, have unclear diagnosis and poor treatment effect, and listen to the opinions of residents and nurses. Listen to the patient's statement, understand the changes of the patient's condition, and solicit opinions on medical treatment, nursing and diet. , and check the implementation of the doctor's advice and treatment effect.
Refer to the above content: Baidu Encyclopedia-Hospital Core System