主持骨科科内查房内容范文
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主持骨科科内查房内容范文英文回答:
Pre-Rounds.
Review overnight admissions and discharges.
Discuss any urgent or emergent cases.
Assign resident responsibilities for the day.
Rounds.
For Each Patient:
Introduction: Name, age, medical history, presenting complaint.
Physical Examination: Inspection, palpation, range of motion, neurological exam.
Radiographic Evaluation: Review X-rays, CT scans, MRIs.
Diagnosis and Assessment: Discuss the patient's condition and possible diagnoses.
Management Plan: Outline the treatment plan, including medications, procedures, and rehabilitation.
Patient Education: Explain the diagnosis and treatment plan to the patient and family.
Post-Rounds.
Resident Assignments: Review resident assignments and ensure they are understood.
Questions and Discussion: Answer any questions or concerns from residents or other team members.
Follow-Up Plan: Determine the frequency and timing of follow-up visits.
Documentation: Complete all necessary documentation, including progress notes, orders, and consultations.
中文回答:
术前查房。
了解新入院和出院患者情况。
讨论所有紧急或危重病例。
安排住院医师当日工作任务。
查房。
对于每位患者:
介绍,姓名、年龄、病史、主诉。
体格检查,视诊、触诊、活动度检查、神经系统检查。
影像学评估,阅览X光片、CT扫描、MRI图像。
诊断和评估,讨论患者病情和可能的诊断。
治疗计划,概述治疗计划,包括药物、手术和康复。
患者教育,向患者和家属解释诊断和治疗计划。
术后查房。
住院医师任务,复查住院医师任务,确保明确。
问题和讨论,解答住院医师或其他团队成员的任何问题或疑虑。
随访计划,确定随访就诊的频率和时间。
文件记录,完成所有必要的文书工作,包括进度记录、医嘱和
会诊。