Common Fallacies in Medical Records for Bedside Evaluation

病歷內容必須正確且提供重要資訊，醫師記載病歷方式，也同時反映其邏輯。在台灣之病歷，內容常見之錯誤包括：病史與理學檢查方面，常誤將個人理論當作事實記載，收集事實也不完整，病史未照發生時間順序紀錄。收集完之事實未作完整之摘要，整理成問題列表。每個問題未以症候群命名，評估每個症候群時（問題）未考慮所有可能之致病因，未以概率大小排序來考慮可能致病因。評估每個症候群時未考慮嚴重度。上述不正確之內容與非邏輯之寫法，易導致錯誤處置。

關鍵字

病歷；診斷；臨床評估

並列摘要

Medical records must be accurate and informative. Medical records reflect a doctor's logic of reasoning. The most common fallacies noted in medical records in Taiwan include the failure to know the differences between facts and personal theory, the failure to record complete medical history and to complete physical examination, the failure to chronologically organize the data, the failure to list all problems and summarize problems according to syndrome, the failure to consider all possible diseased for etiology during the evaluation of a syndrome, the failure to list each possible causative disease by probability, and failure to assess the severity of each problem.

並列關鍵字

medical record ； diagnosis ； clinical evaluation

國際替代計量

Common Fallacies in Medical Records for Bedside Evaluation

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