修复科病历书写

修复科病历书写要求和标准整理自北医的材料

文件一、修复科病历书写要求和标准（整理自北医的材料）一、病历书写总要求1、病历书写自体工整，页面整洁，无自创字，错别字，无严重涂改。

2、病历描述语言通顺，运用术语正确，绘图标记正确。

3、病历附页必须有姓名、病案号、科别及就诊日期。

4、主诉牙（或主诉病）的首诊均按初诊要求书写病历，复诊指住宿呀的继续治疗。

二、病历首页1、姓名、性别、出生日期、籍贯、民族、通信地址、健康状况、初诊科别、日期、邮编及X线片号。

2、药物过敏史（由初诊科室及经治医师负责）3、主诉牙（主诉病）完成治疗后需在病历首页填明日期、科别、诊断、处置。

（1）诊断：部位+诊断名称（2）处置：治疗+（或）辅助检查三、主诉1.初诊主诉：病变部位+主要症状+发病时间修复科主诉的描述不能只写成：“要求修复”，要求描述的是患者的要求和具体部位（如要求修复上颌或下颌左后侧缺失牙或某牙位缺损，若以检查设计为主的初诊患者主诉应写成“上下颌某部位有缺失牙或有缺损，要求作全口检查2.复诊主诉：同一患牙或同一疾病写明治疗后自觉症状四、现病史主诉牙（主诉病）病史的发生、发展、曾经治疗及目前情况。

五、既往史，家族史，全身情况正确记录患者陈述无陈述时记录（一）六、检查（修复科）一）依据牙体缺损、牙列缺损、牙列缺失三种诊断，检查时不同情形略有不同侧重点：1．正确记录牙体缺损所见。

主诉牙牙体缺损及治疗情况，松动度，牙龈，牙周袋，咬合关系、X线。

非主诉牙健康情况及阳性所见。

2．正确记录牙列缺损所见。

（1）缺损部位，数目，剩余牙槽脊条件，缺牙区近远中和上下垂直向间隙大小，有无骨突骨刺；（2）基牙位置，形态，松动度，倾斜度，咬合关系，牙龈、牙周袋和根分歧病变情况；（3）余牙健康情况及阳性所见。

3．正确记录牙体缺失所见。

（1）牙槽骨吸收情况，黏膜弹性，拔牙创及有无骨尖、骨嵴、隆突情况；（2）垂直距离，上下颌弓对应关系，颞颌关系，颞下颌关节情况二）还需检查记录以下情况：1）正确记录牙合类型正常牙合，深覆牙合深覆盖，对刃牙合，反牙合，锁牙合，偏斜。

口腔修复门诊病历书写范文

口腔修复门诊病历书写范文英文回答：Today, I would like to share with you a case from my dental practice. It involves a patient who came to our clinic seeking oral restoration. The patient, Mr. Li, had several missing teeth due to a car accident he had a few years ago. He was having difficulty eating and speaking properly, and it was affecting his confidence and overall quality of life.After conducting a thorough examination and discussing the treatment options with Mr. Li, we decided that a combination of dental implants and crowns would be the best solution for him. Dental implants are artificial tooth roots that are surgically placed into the jawbone, providing a strong foundation for the replacement teeth. Crowns, on the other hand, are custom-made tooth-shaped caps that are placed over the implants to restore the appearance and function of the missing teeth.We began the treatment by placing the dental implants. This involved a minor surgical procedure where we inserted the implants into Mr. Li's jawbone. We then allowed a healing period of a few months to ensure that the implants integrated properly with the bone. During this time, Mr. Li wore temporary dentures to maintain his ability to eat and speak.Once the implants had fully integrated, we proceeded with the next step of the treatment, which was the placement of the crowns. We took impressions of Mr. Li's mouth and sent them to the dental laboratory to create the custom-made crowns. Once the crowns were ready, wecarefully attached them to the implants, ensuring a secure and natural-looking fit.Mr. Li was delighted with the results of the treatment. He was able to eat and speak comfortably again, and his confidence was restored. He mentioned that he felt like he had a new lease on life and was grateful for the transformation that the dental restoration had broughtabout.中文回答：今天，我想与大家分享一起我在牙科诊所遇到的一个病例。

口腔修复门诊病历书写改进及示范

口腔修复门诊病历书写改进及示范1 铸造全冠主诉: 要求全冠保护。

现病史: 右下后牙在我院口腔内科治疗后, 建议其全冠保护。

检查：右下7 远中牙合面大面积水门汀充填体，松（-）, 叩（-) ，龈（—）, 牙周袋(-），X 线示根尖未见病变.诊断: 右下7 牙体缺损。

处理：拟铸造全冠修复右下7 。

今日牙体预备，取印模，灌模型，约日戴冠。

复诊: 上次治疗后无不适主诉。

检查：右下7 全冠预备体, 叩(—）, 龈（—) ，松(-）。

处理：今日戴右下7 铸造全冠, 边缘密合, 固位力好，近远中接触点密，调牙合抛光, 常规消毒，水门汀粘固，嘱注意事项。

2 桩核加烤瓷冠主诉: 要求修复上前牙。

现病史：①上前牙数日前因外伤碰断, 在口腔内科治疗后要求修复。

②上前牙数年前在我院“简单桩"修复后变色，在修复科拆除简单桩并治疗后，要求修复.查: 1 残根, 根面位于龈上（龈下）2mm，叩（2），松(2）, 龈(2），无瘘管, X 线示根充满, 根尖未见病变，牙槽骨未见明显吸收。

印象：1 牙体缺损。

处: 拟桩核加烤瓷冠修复1。

今日1 根面、根管预备，直接法取桩核蜡型, 牙胶封根管口，约日试桩核.复诊：上次治疗后无不适主诉。

查：1 根, 叩（2），龈(2) ，松（2）。

处理: 今日试1 桩核, 边缓密合，固位力好, 常规消毒，水门汀粘固.1 烤瓷冠牙体预备，取印模, 灌模型。

约日试基底冠（制作暂时冠, 氧化锌粘着）。

复诊: 试基底冠。

查：同前。

处: 今日试1 基底冠, 边缘密合，固位力好，调牙合，比色B3，约日试烤瓷冠。

复诊: 同前。

处: 今日试1 烤瓷冠，边缘密合, 固位力好，修整外形，调牙合，病人满意后上釉, 抛光, 常规消毒, 水门汀粘固, 嘱注意事项。