What is the function of medical records?

The first page of the general medical record is the general information of the patient, including name, gender, age, occupation, drug allergy history, etc. Don't underestimate these basic information, such as drug sensitivity history. If the patient is allergic to penicillin, the doctor will prescribe penicillin drugs without knowing it, and the consequences will be unimaginable.

The medical record can record symptoms, physical examination, relevant auxiliary examination, doctor's initial diagnosis, therapeutic drugs, precautions, etc. It records the occurrence, development and treatment of diseases. Even different doctors can basically understand the patient's medical history, the development and changes of the disease and the diagnosis and treatment process through the medical record book, and can also avoid repeated examinations and ineffective treatment methods. Some chronic diseases, such as diabetes, hypertension, hyperthyroidism and anemia. , need to regularly review related indicators (such as blood sugar, blood pressure, thyroid hormone, hemoglobin, etc. ), and doctors need to adjust the treatment plan according to the changes of these indicators. In addition, the medical record is also a legally binding document, which is the written basis for explaining medical behavior between doctors and patients.