动-静脉内瘘功能不良是血液透析患者血管通路最常见并发症,部分患者需要住院治疗,该文分析了因动静脉内瘘功能不良入院患者的入院病历、诊断、手术记录、出院记录等方面的书写特点。 强调,主诉描述要简练规范,现病史书写应围绕血管通路情况进行描述,不可忽视相关既往史,专科体检需要描述供血动脉系统检查及内瘘视、触、听诊情况,手术记录要详细,出院记录中出院医嘱应侧重于对血管通路知识的宣教。

This paper is to analyze medical record characteristics in admission,diagnosis,operation,and discharge of patients with arteriovenous fistula dysfunction, and to discuss its writing focus. It is emphasized that the main symptom should be succinct and standard,that present illness history should be centered on situation of blood access, and that past medical history should not be ignored. Specialist examination should describe not only the blood artery system, but also the visual examination, palpation,auscultation of the arteriovenous fistula. The operation record should be recorded in detail. The doctor's advice in discharge record should focus on propaganda and education of blood access knowledge.