Guangzhou Zhongshan Ophthalmology Department: Precautions for rechecking medical records
After visiting Zhongshan Ophthalmology Department in Guangzhou, patients may need to review medical records regularly to ensure treatment progress and disease control. It is very important to review the medical records. Only by understanding the indicators in the medical records can doctors better provide personalized treatment plans for patients. The following aspects should be paid attention to when reviewing medical records:
Basic patient information
When reviewing the medical record, first check the basic information of the patient, including name, age, gender, contact information, etc. This information is the first step for doctors to establish a good doctor-patient relationship. If the basic information of the patient changes, the medical record should be updated in time so that the doctor can accurately contact the patient and track the treatment process.
In addition, the patient's medical card number is also important information. Doctors can trace the patient's historical medical records, medication, etc. through the card number, so as to better understand the patient's disease development and treatment effect.
Disease medical record
When rechecking the medical record, it is necessary to check whether the diagnosis results and treatment plan in the medical record are consistent with the current situation. If the condition changes or new symptoms appear, the patient should inform the doctor in time to adjust the treatment plan.
In addition, the patient's allergy history and medication history should also be recorded in the disease medical record, which is very important for doctors to carry out follow-up treatment. If the patient is allergic to certain drugs, it should be clearly marked in the medical record to avoid unnecessary risks caused by medication.
In addition, patients need to report their symptoms, pain degree, blood sugar index and other information to the doctor in detail when reviewing their disease records, which helps doctors to fully understand the patient's disease status, so as to develop a more reasonable treatment plan.
Test results
When rechecking the medical record, you should carefully check the results of laboratory tests, including blood tests, eye tests, vision tests, etc. These results are the key basis for doctors to understand the disease progress of patients.
Patients should pay special attention to the changes of abnormal indicators, such as whether the intraocular pressure is normal, whether the corneal curvature is stable, etc. If any abnormality is found, the patient should describe the situation to the doctor in detail and actively cooperate with the doctor for further inspection.
The results of laboratory tests are an important reference for evaluating the treatment effect. By comparing the results before and after the tests, doctors can understand the changes of patients' conditions and adjust the treatment plan in time to improve the treatment effect.
Medication
When rechecking the medical record, carefully check the medication, including the name, dosage and usage of the drug. If the patient has adverse drug reactions or other conditions that need to be adjusted during the treatment, the doctor should be informed in time.
When reviewing the medical record, the patient can also ask the doctor about medication, such as which food and drug interactions need attention, and whether other drugs can be taken at the same time when using drugs. The answers to these questions can help patients better use drugs and improve the treatment effect.
Summary
When reviewing medical records, patients need to check basic information, disease medical records, test results and medication. Only by ensuring the accuracy and integrity of medical records can doctors better understand patients' conditions and develop personalized treatment plans. When reviewing the medical records, patients should also make full use of the communication opportunities with doctors to report the changes of symptoms and medication in detail, so as to obtain better treatment results.
