[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"$fMIZoWNrbUH_MaM8H9_r7o7CStzbmqFUo1tvd9FeoJVY":3},{"answer":4,"createTime":5,"id":6,"options":7,"origin":12,"question":19,"related":20,"source":30,"type":31},[],"2026-05-28 08:02:29",247724207,[8,9,10,11],"急诊病历可由接诊护士代签名","患者\u002F家属需在治疗同意书上签名确认","实习\u002F试用期医生需经上级医师审核并双签名","接诊医生需手写签名(不可打印)",{"count":13,"courseId":14,"courseImg":15,"courseName":16,"workId":17,"workName":18},10,"53e1d2ef4961cca8eea3e23969ad2cb9","https:\u002F\u002Ftihai-oss-cloud.itihey.com\u002Fimg\u002F03a579384a6dc297c89809b582fcc767.png","默认课程","b233038ecb0e4d748e77dac6c2cbbc85","多选题","医疗文件签名与审核的要求包括( )",[21,32,41,50,59,68,77,80,90,99],{"answer":22,"createTime":5,"id":23,"options":24,"question":29,"source":30,"type":31},[],247724194,[25,26,27,28],"急诊患者需记录接诊时间(精确到分钟)","意识障碍患者需记录家属代述的主诉","儿童患者需记录陪同家长姓名及联系方式","外院转诊患者需复制原病历关键内容(无需标注来源)","特殊情况下口腔内科病历的补充记录要求包括( )","v1",0,{"answer":33,"createTime":5,"id":34,"options":35,"question":40,"source":30,"type":31},[],247724197,[36,37,38,39],"及时、完整、规范","简化流程、随意修改","主观推测、模糊表述","客观、真实、准确","口腔内科医疗文件书写的基本原则包括( )",{"answer":42,"createTime":5,"id":43,"options":44,"question":49,"source":30,"type":31},[],247724199,[45,46,47,48],"具体治疗步骤(如"局麻下开髓+根管预备")","费用明细(如"根管治疗费用约800元")","预后评估(如"治疗后疼痛缓解概率90%")","预计复诊时间(如"1周后复诊")","治疗计划的内容应包括( )",{"answer":51,"createTime":5,"id":52,"options":53,"question":58,"source":30,"type":31},[],247724201,[54,55,56,57],"曾接受的治疗(如补牙、根管治疗)及效果","患者既往全身疾病史(如高血压、糖尿病)","起病诱因(如冷热刺激、咬硬物)","症状发展变化(如疼痛从隐痛转为自发痛)","现病史记录的内容应包括( )",{"answer":60,"createTime":5,"id":61,"options":62,"question":67,"source":30,"type":31},[],247724203,[63,64,65,66],"检查记录(口腔及辅助检查)","初步诊断与治疗计划","现病史","主诉","口腔内科门诊病历的基本结构通常包括( )",{"answer":69,"createTime":5,"id":70,"options":71,"question":76,"source":30,"type":31},[],247724204,[72,73,74,75],"患者对治疗的恐惧心理(主观情绪)","龋坏的部位、深度(如邻面深龋)","牙周袋探诊深度(如右下6牙周袋5mm)","黏膜病损的范围、性质(如颊黏膜溃疡直径0.5cm)","口腔检查记录需重点描述的内容包括( )",{"answer":78,"createTime":5,"id":6,"options":79,"question":19,"source":30,"type":31},[],[8,9,10,11],{"answer":81,"createTime":82,"id":83,"options":84,"question":89,"source":30,"type":31},[],"2026-05-28 02:09:37",247724208,[85,86,87,88],"使用患者原话(如"牙疼3天了")","包含医生初步诊断(如"牙髓炎")","简明扼要,不超过20字","描述主要症状、部位及持续时间","主诉的书写要求包括( )",{"answer":91,"createTime":5,"id":92,"options":93,"question":98,"source":30,"type":31},[],247724211,[94,95,96,97],"需标注诊断依据(如"温度测试阳性+X线根尖阴影")","主要诊断为当前就诊的主要问题(如"慢性牙髓炎急性发作")","次要诊断需合并记录(如"右下8阻生齿")","可省略鉴别诊断(因门诊病历篇幅限制)","关于诊断的书写规范,正确的是( )",{"answer":100,"createTime":5,"id":101,"options":102,"question":107,"source":30,"type":31},[],247724213,[103,104,105,106],"在修改处上方或右侧注明修改时间及签名","直接涂黑或粘贴覆盖错误部分","用双线划去错误内容,保留原记录清晰","电子病历修改需留痕并标注修改人","医疗文件修改的规范做法是( )"]