Problems in Usage of Medical Terminology in Physical Examination Records and Relevant Improvement Measures

Abstract

AbstractPhysical examination results need to be systematically and truly 
recorded with standardized terminology. The main problems existing 
in the recording process include: (1) recording with non-standard 
medical terms; (2) wrong description; (3) reversal of recording order; 
(4) incomplete recording; (5) ambiguous wording; (6) name of the disease or symptom instead of signs; (7) lack of objective and true recording; (8) classifying severity of signs in an ambiguous manner; (9) description being too simple; and (10) controversial recording. We should improve the understanding of the importance of language standardization, pay attention to the standardization training of clinical skills, constantly update medical and humanistic knowledge, improve management of systems, read many excellent textbooks from presses and examples set by medical journal editors to realize the standardization of medical terminology in physical examination records.