What details should we pay attention to in reviewing medical records?
Reviewing medical records is an important basis for doctors to evaluate the treatment effect of patients and adjust the treatment plan. In Guangzhou Zhongshan Ophthalmology Department, doctors will pay special attention to the following details during the reexamination to ensure that patients' health is effectively managed and treated.
1. Change of illness
By comparing the initial medical record and the recheck medical record, doctors can understand the changes of patients' condition. They will carefully observe whether the patient's symptoms have improved or worsened, and understand the progress of the disease by examining the patient's eye structure and function.
The doctor will pay attention to whether the patient has new symptoms, such as eye pain, blurred vision, congestion, etc. These symptoms may indicate the deterioration of the disease or the occurrence of complications. The doctor will also observe the changes of the eye structure, such as whether there is bleeding, edema, inflammation, etc., and whether the position and movement of the eyeball are normal.
In addition, the doctor will evaluate the patient's vision and intraocular pressure. The change of vision may reflect the improvement or deterioration of the condition, and the change of intraocular pressure may indicate the development of glaucoma and other eye diseases.
2. Treatment effect
The review medical record also includes the treatment received by the patient and the effect of treatment. The doctor will check whether the treatment is carried out according to the treatment plan and evaluate the effect of the treatment.
The doctor will observe whether the patient's symptoms have improved, such as whether the vision has obviously recovered and whether the eye pain has alleviated. They will also examine changes in the structure and function of the eye to determine whether the treatment has a significant effect.
In addition, the doctor will evaluate whether the treatment plan needs to be adjusted according to the examination results in the recheck medical record. If the treatment effect is not satisfactory, the doctor may suggest changing the drug, increasing the treatment dose or taking other treatment measures to improve the patient's condition.
3. Drug use
It is also necessary to record the drug use of patients in detail in the medical records. The doctor will know whether the patient uses the medicine on time and in proper amount, and whether there are adverse drug reactions.
The doctor will ask the patients whether they have missed taking drugs and remind them to comply with drug use regulations to ensure the effectiveness of drugs. If the patient has an adverse drug reaction, the doctor will adjust the dosage of the drug or change other drugs according to the condition to reduce the occurrence of adverse reactions.
In addition, doctors will also pay attention to whether the patient has used other drugs, such as other eyedrops, oral drugs, etc. These drugs may interfere with the treatment of eye diseases, so doctors need to know this information in order to carry out a reasonable treatment plan.
4. Lifestyle and eating habits
In addition to medication, the patient's lifestyle and eating habits may also have an impact on the condition. The doctor will ask the patient about his/her work, living environment and daily eating habits to understand whether there are possible pathogenic factors.
For example, long-term eye use, eye fatigue, and eye irritation caused by the working environment may aggravate the symptoms of eye diseases. The doctor will give corresponding guidance to patients, such as reasonable arrangement of work and rest time, correct use of eye care products, etc., to alleviate symptoms and promote recovery.
In addition, doctors will also pay attention to the patient's eating habits, especially whether they take enough vitamins and antioxidants. These nutrients are very important for eye health, and doctors may recommend patients to increase their intake or supplement them appropriately.
Summary
When reviewing the medical records in Zhongshan Ophthalmology Department in Guangzhou, the doctor will pay attention to the details of the changes in the condition, treatment effect, drug use, lifestyle and eating habits.
By fully understanding the patient's condition and treatment, doctors can timely adjust the treatment plan and provide personalized treatment suggestions to promote the patient's recovery and eye health.
