Physical treatment record sheet for rehabilitation medicine department and use method thereof

Abstract

The invention discloses the technical field of medical treatment, relates to the technical field of medical record forms, and particularly relates to a physical treatment record sheet for a rehabilitation medicine department and a matched use process thereof, which are used for standardizing and efficiently recording physical treatment process information of a patient. In the physical treatment work of the rehabilitation medicine department, information such as treatment items, time and treatment effect of a patient needs to be recorded in detail, so that a doctor tracks the treatment progress, evaluates the effect and adjusts a scheme. A traditional recording mode has the problems that information is dispersed, key content (such as accurate identification of a treatment part and contraindication associated records) is easy to omit, a signature confirmation process is not clear and the like, medical work efficiency and quality are affected, and long-term management and tracing of medical data are not facilitated. Therefore, a record list which is more reasonable in design and more complete in function is needed to optimize the recording work of the physical therapy.

Description

TECHNICAL FIELD

[0001] The application belongs to the technical field of medical treatment, and specifically relates to a physical treatment record sheet for a rehabilitation medical department and a use method thereof. BACKGROUND

[0002] In the physical treatment work of the rehabilitation medical department, information such as treatment items, time, curative effect and the like of a patient needs to be recorded in detail, so as to enable a doctor to track treatment progress, evaluate effect and adjust a scheme. The traditional recording mode has problems such as dispersed information, easy omission of key contents (such as precise identification of a treatment site, associated recording of contraindications), unclear signature confirmation process and the like, which affect medical work efficiency and quality, are not conducive to long-term management and tracing of medical data, and therefore a recording sheet with more reasonable design and more perfect function is needed to optimize the physical treatment recording work. SUMMARY

[0003] A physical treatment record sheet for a rehabilitation medical department is provided, which realizes systematic integrated recording of information such as patient basic information, treatment prescription, treatment process (time of multiple items, signature), curative effect observation, contraindications and the like, standardizes a treatment process, improves recording accuracy and convenience, and assists medical decision-making and data management.

[0004] Structure of the record sheet

[0005] • Patient basic information area: name, gender, age, department, outpatient / hospitalization number, diagnosis writing columns are set, which are used to input patient basic identity and illness information.

[0006] • Treatment prescription area: contains writing items of items 1-3, each item corresponds to daily frequency, site, dose, note column, which clearly defines the specific content and parameters of physical treatment; the right side is configured with a head (front, left, right view), a schematic diagram of a trunk human body, which is used for precise marking of a treatment site.

[0007] • Contraindications area: common contraindications such as malignant tumors, metal objects in the body, pacemakers and the like are listed, and an "other" supplementary column is set, which prompts the patient to inform obligation of abnormal conditions.

[0008] • Treatment process recording area: the number of times, date, start time, end time, doctor signature, patient signature column are set according to items one, two and three, which record the execution time of each treatment and the confirmation information of both parties, and the number of times covers the treatment period (such as 1-30 times).

[0009] • Curative effect observation and confirmation area: curative effect observation options (recovery / remarkable effect, effective, ineffective, deterioration) are set, and the signature of the patient / family member confirming the treatment item and the number of times, relationship explanation and date column are set.

[0010] Use method

[0011] 1. Information entry preparation: Before treatment, medical staff fills in the patient's basic information area, such as patient's name, gender, and other basic information, and enters the diagnosis results in the diagnosis column.

[0012] 2. Treatment prescription filling: According to the treatment plan, fill in the specific content of items 1-3 in the treatment prescription area, mark the daily frequency, mark the treatment site on the human body diagram, fill in the dose and remarks (such as special treatment requirements); at the same time, if the patient has contraindications, check or supplement the contraindications area.

[0013] 3. Treatment process record: Each time of physical therapy, medical staff fills in the treatment date, start and end time under the corresponding item and number of times column, and doctor's signature after completion, patient (or family member) signature after confirmation.

[0014] 4. Efficacy and confirmation: During or after the treatment period, medical staff checks the efficacy observation results according to the patient's recovery; patient (or family member) checks the treatment items and times, signs in the confirmation area, marks the relationship with the patient and fills in the date.

[0015] Advantages

[0016] 1. Comprehensive information integration: The associated information such as patient's basic information, treatment plan, process record, efficacy evaluation and contraindications is presented comprehensively, which facilitates medical staff to quickly review and analyze, and improves medical work efficiency.

[0017] 2. Precise treatment site: Human body diagram helps to mark the treatment site, reducing ambiguity in site description and improving the accuracy of treatment operation and record.

[0018] 3. Clear process specification: The signature confirmation process of doctor and patient (family member) in treatment process is clear, which strengthens the standardization and traceability of medical behavior and reduces the risk of medical disputes.

[0019] 4. Convenient data management: Standardized record format facilitates electronic archiving and statistical analysis of medical data, providing reliable data support for rehabilitation treatment research and quality control. BRIEF DESCRIPTION OF DRAWINGS

[0020] Figure 1 (Treatment process record and efficacy confirmation page)

[0021] • Show the structure of the treatment process record area and efficacy observation and confirmation area of the record, including the number of times (9-30 times), time, signature column layout of items 1, 2 and 3, and efficacy observation options and patient confirmation information column.

[0022] Figure 2 (Patient information and treatment prescription page)

[0023] • The layout of the patient basic information area, the treatment prescription area (including item 1-3 parameter columns), the precautions and contraindications area, the human body diagram, and the record of the first 8 times of the treatment process area is presented, which clearly shows the overall framework and information filling area distribution of the record sheet. DETAILED DESCRIPTION

[0024] Record sheet making

[0025] A medical writing-resistant and non-permeable paper is used to design and print the record sheet according to the attached drawings, which ensures that each filling column is clear and the human body diagram is accurate. The number of times can be adjusted according to the actual needs of the hospital.

[0026] Actual use process

[0027] 1. Before the first physical therapy of a new patient, the nurse or doctor fills in the patient's basic information and diagnosis results on the first page of the record sheet after receiving the treatment order. Figure 2

[0028] 2. The attending doctor fills in the name of each treatment item, the daily frequency, and the dose (such as the intensity and duration of physical factor treatment) in the treatment prescription area according to the rehabilitation plan, and marks the treatment site on the human body diagram with a marker pen (such as a medical marker pen). Special notes are supplemented. If the patient has contraindications, check or supplement the relevant information.

[0029] 3. Before each treatment, the therapist checks the patient's information and treatment prescription, then performs the physical therapy operation. After the operation is completed, the therapist fills in the date, start and end time, and signs in the corresponding item and number of times of the treatment process record area. The patient (or family member) confirms the treatment execution and signs. Figure 1 Figure 2

[0030] 4. When the treatment reaches a certain stage (such as every week or the end of the treatment period), the doctor assesses the patient's efficacy and checks the corresponding results in the efficacy observation area. After the treatment period ends, the patient (or family member) checks all treatment items and times, confirms that there is no error, signs in the confirmation area, fills in the relationship with the patient and the date, and the record sheet is returned to the patient's medical record for archiving.​​​

Claims

1. A physical therapy record sheet for rehabilitation medicine, characterized in that, include: The patient's basic information area includes fields for name, gender, age, department, outpatient / inpatient number, and diagnosis. The treatment prescription area includes fields for daily frequency, location, dosage, and remarks for items 1-3; front, left, and right side views of the head; and a schematic diagram of the torso. The section on cautions and contraindications includes a list of contraindications for malignant tumors, internal metal objects, pacemakers, and an additional "other" supplementary section. The treatment process record area includes sections for setting the number of times, date, start time, end time, doctor's signature, and patient's signature for each of the three treatment items; The efficacy observation and confirmation area includes efficacy observation options, as well as signatures, relationship explanations, and date columns for patients / family members to confirm treatment items and frequencies.

2. The physical therapy record sheet for rehabilitation medicine as described in claim 1, characterized in that: The torso diagram is used to accurately mark the physical therapy sites and assist in recording treatment prescription information.

3. A method of using a physical therapy record sheet in rehabilitation medicine, based on the physical therapy record sheet in rehabilitation medicine as described in any one of claims 1-2, characterized in that, Includes the following steps: Step 1: Before treatment, fill in the patient's basic information and diagnosis results in the patient's basic information area; Step 2: Based on the treatment plan, fill in the parameters of each item in the treatment prescription area, mark the treatment site on the torso diagram, and add contraindication information; Step 3: After each treatment, fill in the time in the treatment process record area and have both the doctor and the patient sign it; Step 4: During or after the treatment cycle, check the efficacy observation results in the efficacy observation and confirmation area. After the patient / family member verifies the results, sign and indicate the relationship and date in the confirmation area.

4. The method of use according to claim 3, characterized in that: In step two, the treatment area is precisely marked using a human body diagram, improving the accuracy of the treatment area record.

5. The method of use according to claim 3, characterized in that: In step three, the treatment process is recorded in a standardized manner by having both the doctor and the patient sign, thus enabling traceability of medical practices.

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