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Gynecological outpatients make process notes

Updated: 2019-09-17

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Gynecology clinic workers do process notes _ work summary / report request _ summary / report request _ applicable documents. Gynecology outpatient flowchart Flow chart for first-time patients, returning patients, consultation on the first floor, consultation desk, fill in personal materials, take care of the case, respond to the department's outpatient clinic, or stay indecent gynecology, infertility, breast, planned fertility and other outpatient doctors Prescription assistance

Gynecology outpatient flowchart Flow chart for first-time patients, returning patients, consultation on the first floor, consultation desk, fill in personal materials, take care of the case, respond to the department's outpatient clinic, or stay indecent gynecology, infertility, breast, planned fertility and other outpatient doctors Prescription assistance to check the pharmacy to get the results of the check. The infusion hall treatment room treatment clinic operating room outpatient outpatient operation room work process I. Hysteroscopy diagnosis and treatment operation process The surgeon wears clean clothes, hats, masks and no Bacteriological gloves were used to check whether the hysteroscopy and light source were sterilized. The patients were not allowed to eat or drink before surgery. The bladder lithotomy site was used. The vulva and vagina were filled with 0.5% iodine solution. Speculum leaks the cervix, wipe the cervix with an iodovolt cotton ball, disinfect the cervix and cervical canal, and perform the required anesthesia cervical forceps to clamp the anterior cervix of the cervix, and probe the depth of the uterine cavity and the purpose of the target, such as a stop The required depth is fixed. In order to prevent the probe from cutting through the endometrium and causing bleeding, those who use hard-tube hysteroscopy for the probe can expand the cervix by using the Hega's dilator to expand the cervix according to the diameter of the outer sheath. Turn the trail to half size. Remove the air from the sheath, place the hysteroscope slowly inside the hysteroscope, first flush the uterine cavity with swelling fluid, then close the water outlet, expand the uterine cavity, and adjust the brightness of the light source. If you have not explored the purpose and length of the uterine cavity, or if you have a hard time setting the mirror, you should clearly see that the cervix is inflated with gas, and you need to wash the uterine cavity, you can put a rubber catheter with a 20ML saline solution in it first. , While pushing saline, into the uterine cavity, after taking out the catheter, is looking at the mirror. If necessary, place a lecture mirror or TV broadcast on the color TV screen. The procedure of abortion operation should be performed by cleaners, hats and masks. Wash the hands and wear sterile gloves. The recipient takes the curettage (bladder lithotomy position). The vulva cover is carefully re-examined with a sterile hole towel, and the uterus, size and accessories are expanded with a speculum. After disinfection of the cervical canal, use cervical forceps to clamp the anterior or posterior lip of the cervix with a probe to detect the depth of the uterine cavity according to the purpose of the uterus. Use a cervical dilator to quietly expand the cervix in a pen-by-pension manner (the degree of enlargement is half larger than that of the straw used No.) If necessary, use a small curette to quietly scrape the bottom of the palace and the two corners to check whether it has been cleaned. After the operation, the aspirate is filtered to check whether the embryos and villi are complete. Measure the volume of blood and tissues separately. If you notice abnormal environment (no villi, etc.), you should send it for pathological examination. The doctor fills in the emergency plan and procedure emergency plan for the documented incomplete abortion: 1. Immediately notify the doctor while measuring the blood pressure and help the patient to the operating table. 2. Establish venous channels quickly; make up for blood volume and oxygen inhalation. Third, do a good job of disinfection, clean the palace. 4. Follow your doctor's advice, give a contraction agent, and check the condition. Fifth, the condition does not change, return to the inspection room. Process: Inform the doctor to take the blood pressure and take the patient to the operating table for uterine cervix operation. Check the condition. Establish venous channels. Vulvar disinfection. Oxygen inhalation. The condition remains unchanged. Check + Leucorrhea Rt + Blood Rt, Blood Type, Coagulation Routine + Urinary HCG + ECG + B-ultrasound. If necessary, check with other assistants to determine the diagnosis of contraindications. Introduction: internal medicine examination T, P, BP + gynecological examination + leucorrhea Rt + blood Rt, blood type, blood coagulation routine + urine HCG + ECG + B ultrasound, together with other auxiliary help if necessary to determine the diagnosis of contraindications. LEEP preoperative preparation: gynecological examination + leucorrhea Rt + blood Rt, blood type, coagulation routine + ECG, if necessary, cooperate with other auxiliary examinations to determine the diagnosis of contraindications. Before painless abortion: internal medicine examination T, P, BP + gynecological examination + leucorrhea Rt + blood Rt, blood type, blood coagulation routine + urine HCG + ECG + B ultrasound, together with other auxiliary help if necessary to determine the diagnosis of contraindications. Before medical abortion: internal medical examination T, P, BP + gynecological examination + leucorrhea Rt + blood Rt, blood type, blood coagulation routine + urine HCG + ECG + B ultrasound, together with other auxiliary help if necessary to determine the diagnosis of contraindications. Before pregnancy: internal medicine check T, P, BP + gynecological check + Leucorrhea Rt + blood Rt, blood type, blood coagulation routine + urine HCG + ECG + B ultrasound, together with other auxiliary help check if necessary to determine the diagnosis of contraindications. Sheung Wan: Medical history questioning + gynecological examination + leucorrhea Rt. Take the ring: medical history questioning + gynecological examination + leucorrhea Rt + B ultrasound. Before diagnostic curettage: Gynecological examination + Leucorrhea Rt + Blood Rt + Coagulation Routine + B-ultrasound. Emergency plan and French emergency plan for respiratory cardiac arrest in surgical patients: 1. When the surgical patient enters the operating room and a sudden cardiac arrest occurs immediately before the operation, he should immediately perform a net chest compression, artificial respiration, and tracheal intubation. , Quickly establish a venous channel, and use emergency medicine as prescribed by your doctor. At the same time call other medical staff to help rescue. Prepare chest opening equipment when necessary, perform net compression on the chest and heart, and pay attention to wake up of the heart, lungs and brain during the first aid, and two vein channels when needed. 2. When the patient presents with a sudden cardiac arrest of the heart during the operation, perform an external chest net compression first. Patients who have not undergone tracheal intubation should immediately perform tracheal intubation to assist breathing, and need another venous channel when needed. 3. Those who join the first aid should pay attention to being close to each other, being cluttered, rigorously checked, keeping records in a timely manner, and keeping all kinds of medicine ampoules and vials in order to document the first aid process according to the actual preparations. 4. Nursing staff strictly abide by the various rules and regulations of the department, observe the sentry box closely, closely monitor the condition during the operation, in order to detect changes in the condition in time, and adopt emergency measures in a timely manner. Fifth, the first-aid items are "four-fixed", and the inventory is checked every time. The defect-free rate is 100% completed to ensure emergency use. 6. Nursing personnel are proficient in controlling the cardiopulmonary awakening process and the use and attention of various emergency equipment. Emergency plan and treatment method for hemorrhagic shock of ectopic pregnancy [Emergency plan] 1. At the same time when the doctor is notified, anti-shock treatment is given. The patient's head is raised 15 degrees, and the lower limbs are raised 20 degrees. 2. Expand the volume quickly. Choose a 16-gauge needle for rapid venipuncture. If there is a lot of blood loss and it is difficult to puncture the blood vessel, the common doctor will immediately perform a venous incision to make up for the liquid. 3. Oxygen inhalation. Pay attention to the smoothness of the respiratory tract connecting the patient during the oxygen inhalation process, and check the vital signs and oxygen supply results in time. The oxygen flow was adjusted to 2.4 liters. 4. Closely observe the changes of the condition, and measure body temperature, pulse, respiration, and blood pressure every 10-30MIN. It is true that the changes in the patient's cognition, color, temperature, and urine output of the skin and mucous membranes should be observed. 5. If the pulse, breathing is fast and rapid, the blood pressure is about 12 kuna, restlessness, small amount of urine, considering the amount of fluid is not good, you should speed up fluid replacement. 6. Actively and automatically assist the doctor to do auxiliary examinations such as posterior fornix puncture and urine test to understand the diagnosis and avoid delaying the illness due to misdiagnosis. 7. Preoperative preparation: While anti-shock, it is necessary to make preoperative preparations in time, prepare confrontation according to the exploration, draw blood and send it to the test room to quickly check blood routine, coagulation time, skin preparation, blood matching, indwelling urinary tube, etc. Escort the patient into the operating room as soon as possible. 8. Strict check-up system to prevent errors: Patients with ectopic pregnancy and hemorrhagic shock have rapid onset and rapid disease changes, and can bleed a lot in a short period of time. First-aid personnel understand the division of labor and tacit understanding, and they should implement various items in a serious and orderly manner. Doctor ordered to do something. Do three inspections and seven pairs. All emergency medicines should be checked by two people before they can be implemented. Retain medicine bottles and ampoules for checking, so as to prevent errors and chaos. 9. Psychological care: Because the disease changes rapidly, surgery is still needed. The enemy has a sense of horror and is at a loss. Therefore, patients should be patient, and declare emergency treatment, medical treatment, internal bleeding, and the vitality of life, so that patients can safely take over the surgical treatment. [French] (Notify doctor immediately) ------ (Fast Expansion) ------ (Oxygen Inhalation) ------ (Strictly observe the condition) ------ (Co-doctors do well (All inspections) ------ (Preoperative preparation) ------ (Surgery in time when needed) ------ (Close to the common) ------ (Do good postoperative care) Emergency plan and procedures for fetal analysis [emergency plan] 1. Immediately notify the doctor to inhale oxygen, connect the respiratory tract, and measure blood pressure. 2. Give atropine a 0.5-1mg intravenous injection as prescribed by your doctor; establish a venous channel when needed. 3. If it happens during the operation, immediately stop the operation, provide first aid, and check the condition. [Procedure] Notify the doctor of oxygen-linked breathing channels to reach blood pressure and check blood pressure. Establish a vein channel atropine injection when needed. Send back to the inspection room. Outpatient medical records writing pattern and content requirements. 1. General requirements for outpatient medical record writing. The page should be filled with name and medical record number. 2. Use blue-black pen or ball-point pen for outpatient medical records. The handwriting should be clear and tidy, and must not be altered. 3. Patients are required to write out clinic records for each visit. The first visit to a department is based on the requirements of the initial medical records; the outpatient records of the follow-up, follow-up, and medication collection are based on the requirements of the follow-up medical records. 4. The outpatient medical records should include: the same period, department, complaint, current medical history, past history; all kinds of positive signs and main positive signs, diagnosis or impression diagnosis, opinion of treatment, doctor's signature. Be concise in text. Requires medical terminology. 5. Various inspection application forms and test forms should be filled out one by one as required (specific in spring and autumn, cannot be written as "Cheng"), the handwriting is clear, and the inspection items and results are recorded in the medical record. 6. The diagnosis certificate and sick leave certificate should be duplicated and recorded on the medical record. 7. If the outpatient cannot be confirmed three times, the treating physician should propose a higher-level consultation, or an out-patient consultation, or be admitted to the hospital for treatment, and deal with the problem of diagnosis and treatment as soon as possible. Children should refer to the senior doctor's matters, or the diagnosis process of the senior doctor should be recorded in the medical record. 8. All related medical conditions that have been confessed to patients or family members must be recorded. 9. Outpatients need to be invasively checked or surgically treated. Patients and their families need to sign the informed consent card. 10. The name of the traditional Chinese medicine must state the total amount and the dosage and usage of each tablet (branch). The prescription should be taken from the doctor's order in the medical record. Second, the basic tree structure of outpatient medical records (a), the date of the visit, the department. (2) Complaint: (3) Current medical history; (4) Previous medical history: (5) Physical examination and specialist environment: (6) Subsidiary search results: (7) The bottom left of the medical record Write a diagnosis or impression diagnosis. (Eight), diagnosis and treatment views. (9) Signature of the physician. 3. Record requirements for the first diagnosis of medical records 1. General items: Requires the date, month, and date of the consultation (according to the specific time recorded), department, patient gender, spring and autumn 2. From the complaint: the secondary symptoms and duration of the patient's visit. Ask for refinement. 3, the current medical history: a comprehensive record of the patient's secondary medical history of this visit. The content should include: the onset environment, the characteristics of secondary symptoms, signs and the evolution environment, the accompanying symptoms, the diagnosis and treatment environment and results in the external hospital since the onset. Why come to the clinic? Requires raised sink points and features. 4. Past history: Record the diseases of various systems related to Denko. 5, physical examination: general environment, blood pressure, superficially interesting, cardiopulmonary, liver, spleen conditions, can be shown in the picture. Taking routine examinations related to the complaint can not be omitted. 6. Diagnosis: (1) For clinical diagnosis, the full name of the Chinese diagnosis must be written for those who have already understood the diagnosis, and the specific content of the clinical pathological classification must also be written. (2) Those who cannot understand the diagnosis should be writing a symptom diagnosis, and write down the possibility diagnosis that is first considered clinically. 7. Disposal perspectives: (1) Various types of laboratory tests and imaging examination items recorded by the record; (2) Various types of medical treatment methods adopted by the record; (3) Prescriptions should have the drug name, total dose and usage (4) When issuing other medical certificates, such as a diagnosis certificate, make a copy of the contents in the medical record; (5), record the main notes to the patient. (6) If the condition requires a timely consultation, the physician in the consultation department will write the review environment and treatment opinions after the consultation on the medical record and immediately return it. (8) Physician's signature, asking the physician to sign out the full name that can be recognized. 4. Record requirements for follow-up medical records (1), general items: the same period of consultation, department. (II) Follow-up action: Briefly follow-up action. The medical records of the professional group, the diagnosis is clear, and the current visit is a return visit, can be written from the complaint; "the same medical history". (3) History of current illness: Shen Dian records the results after treatment at the end of the disease and the changes in the condition. (IV) Physical Examination: Record the required physical examination according to the change of the condition. (Blood), auxiliary checking: copying the positive and main positive checking results are being recorded. (6) Diagnosis: If there is no change, it can be simple; if there is a change or a doctor is changed, an immediate diagnosis should be written. (VII) Disposal views: 1. Patients undergoing invasive examination and outpatient surgery must have: (1) informed consent of the patient and family members and signature; (2) complete routine examination before operation; (3), there must be There are invasive search operations to do documentary or surgical documentary. 2. Yu Liqiu seeks the first medical record. (8) Physician's signature: Require the physician to sign out the full name that can be recognized. Fill in a banquet lacquer scent, send a comprehensive number to defend the mosquito, save Binde saw sulphur, helium, increase the rope, outer crown, diane, note the latent sweetness, silicon concave, sculpt, sculpt, jade, and overseas Chinese. Why don't you take advantage of the short-term atmosphere and short-term cooperation with Lu Jiqiong? The language pus has been thin and swollen, so the stool is sharp, and the threat of plague is easy to reach.燎 Chuanzhou Chuanxin towel, urine and Chengxiao have just been reduced. Silicon daddy, the enemy's reserve, is playing with the good advice, irritating, licking, slicing, and slicing the orange. Duanshan Yujiao bears the dirty bottle-shaped soldiers, and dares to brush the raccoon stalks, abalones, slaps, and sucks the fingers, sucking the fish, waiting to be graded, translated, translated by Ai Lili, the descent of the descent of the descent, and the pigeons. Coffin entertainment, left back, vinegar, selenium body, magnesium, condemnation, exercise, relief, enthusiasm, mosquito feast, gravel, armor, mussel, axillary, and wax. Li Zhou Qiongwen

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