1) General items: native place (province, city or county must be specified), date of admission: time should be indicated for emergency or serious illness.
For those who should fill in the year, month and day illness statement, fill in "patient"; If it is described by others, the reliability should be explained. 2) Chief Complaint ● There are two space bars between the main content of the electronic medical record and the main complaint.
the following subheadings, such as "current medical history", have the same distance requirements as the main text. ● The main symptoms, location and duration of the patient's admission (if the time is short, such as acute abdomen, the number of hours should be indicated), such as "continuous fever for 6 days, red maculopapular rash all over the body for 3 days".
● It is not advisable to replace symptoms with diagnosis or test results. ● When there is more than one chief complaint, it should be listed separately in the order of occurrence, such as "intermittent empty abdominal pain for 1 year, tarry black stool for 1 day"; Frequent urination and urgency for 3 hours.
3) Current medical history ● Accurately record the onset date, the onset urgency, the onset inducement, the occurrence time of each important symptom, and its development and change process in chronological order. Negative symptoms related to differential diagnosis should also be recorded (with symptomatology and differential diagnosis as the main content).
● When describing symptoms, we should focus on the key points and get a system. For example, when describing pain, we should clarify the location, time, nature, degree and other related factors, as well as the influence of treatment. ● Ask the accompanying symptoms according to the system to avoid omission.
● Past examination and treatment. ● If the details of accidents, suicides or killings are related to the illness, they should be recorded objectively and truthfully, and no subjective comments or speculations are allowed.
● Those who have not recovered from important injuries in other departments and still need treatment should be described in another paragraph. 4) Past history ● General health is strong or weak.
● The history of acute infectious diseases is in chronological order. Record the occurrence time of the disease, the treatment result and whether there are any complications.
If there is no history of infectious diseases, it is also necessary to record the infectious diseases related to the current condition that did not occur for reference. If you have herpes zoster, you should ask if you have a history of chickenpox. ● Whether it has been vaccinated, its type and the date of the last vaccination.
● Inquire about diseases according to the system, including five senses, respiratory system, circulatory system, digestive system, urogenital system, blood system, neuropsychiatric system and motor system (muscles, bones and joints), history of trauma, operation, poisoning and drug allergy. ● The names of allergic drugs should be written in black with character borders.
after the electronic medical record is printed, the doctor draws a red line under the drug name with a red pen. If you are allergic to penicillin, write it as "allergic to penicillin" 5). Personal history ● Place of birth and experience Pay special attention to natural foci and endemic areas, indicate the year of migration, and indicate the specific foci or water sources, such as whether there is a history of contact with blood-sucking early disease.
● Life and habits include eating habits, tobacco and alcohol hobbies. ● Past and current occupations and their work conditions include the time of enlistment or participation in work, arms or types of work, positions, and contact history of patients with toxic substances, radioactive substances and infectious diseases.
● The menstrual history from menarche to the present, the number of days between each menstrual period and the duration of each menstrual period, and the age of amenorrhea can be expressed in the following simple ways: menarche age, the number of days between menstrual periods, the age of amenorrhea or menarche (the number of days between menstrual periods)/(the number of days between menstrual periods), or the age of amenorrhea can be described in language, for example, 16 3~4 3~32 48 or electronic medical records can be described in language or below. It should also be noted whether there is pain during menstrual cramps, the amount of menstruation, color and its characteristics, and the date of the last menstruation.
● Marital status and production history When did you get married? If your spouse is dead, state the cause and year of death, whether the production is normal, and whether there is any history of premature delivery or abortion, birth control and sterilization. ● History of smelting tour For suspicious patients, foreign guests and those who have been abroad for more than half a year, they should be asked if they have a history of cleanliness.
6) Family history ● Health status of father, mother, brother, brother, sister and children. If dead, state the cause of death.
● In case of suspected diseases caused by genetic factors and life contact factors, ask whether there are similar patients in the family. Note: The past history, personal history and family history of readmission can be simplified if there is nothing special.
7) Physical examination ● General conditions: temperature, pulse, pulse condition, breathing (frequency and depth), blood pressure, height and weight (if necessary); Development (normal, abnormal, poor); Nutrition (good, medium, poor, emaciation, obesity); * * * and posture (such as flexion position, sloping position, etc.), complexion (such as ruddy and dull, etc.); Expression (anxiety, pain, chronic illness); Consciousness (lucidity, lethargy, semi-coma, coma) and speech state (clearness, fluency, answering questions to the point), cooperation during examination, etc. ● Skin color (normal, flushing, cyanosis, yellow staining and pallor), elasticity, and presence of edema, sweating, purpura, rash, pigmentation, vascular spiders, scars, wounds, ulcers and nodules; And clearly describe its location, size and degree.
● lymph nodes whether there is swelling in the whole or local lymph nodes, please indicate the location (submandibular, behind the ear, neck, clavicle, axils and groin, etc.), size, number, hardness, tenderness and adhesion; Whether there is red heat, fistula or scar on local skin. 2. model writing of hospital medical records
model writing of Chinese medicine (integrated traditional Chinese and western medicine) medical records Name:. Gender: Male age: 5 years old Nationality:. Place of birth:. Marital status:. Unit:. Postal code:. Permanent address:.
Admission time: 1: on April 13th, 22. Medical history collection time: 1: on April 13th, 22. Presenter: Reliability of the mother of the child: basically reliable onset of solar terms: Chief complaint after Qingming Festival: recurrent fever and cough for 5 days. Current medical history: The child started to have fever, cough, phlegm, stuffy nose and vomiting stomach contents five days ago, and visited our hospital several times. Today, I came to the outpatient department of our hospital again for treatment. In order to further systematically treat, I was admitted to the hospital from the outpatient department.
symptoms at admission: mental fatigue, fever, cough, expectoration, shortness of breath, vomiting of stomach contents once, earache, tinnitus, anorexia, poor sleep, bad stool, three times a day, and micturition. Past history: healthy in the past, denying the history of chickenpox, measles, tuberculosis and hepatitis.
personal history: the mother was healthy during pregnancy, delivered at full term, gave birth to her first child, and her weight and height at birth were unknown. There is no history of asphyxia and hypoxia at birth, no pathological jaundice, mixed feeding, supplementary food added on time, normal growth and development, normal intelligence, and timely vaccination.
allergic history: private prosecution of Qingkailing allergic history, denial of other food and drug allergic history. Menstrual marriage and childbearing history: family history: parents' health.
deny the family history of hereditary diseases. Physical examination T 37℃ P 92 times/min R 2 times/min bp Overall condition: looking at God: conscious, tired, normal expression.
color: normal face, white color. Appearance: normal development, average nutrition, and thin body shape.
posture: * * * normal, natural posture, normal gait. Voice: clear language, moderate language strength, cough, no hiccups, belching, wheezing, * * * and other abnormal sounds.
odor: no special odor. Tongue image: red tongue with white fur.
pulse condition: pulse floating number. Skin, mucosa and lymph nodes: skin mucosa: the skin mucosa has no yellow staining, normal texture and elasticity, slightly hot skin, no sweat, no macula, sores, scars, tumors, abnormal acupoint signs, vascular signs, spider nevus, pigmentation, etc., and no skin scratch signs.
Lymph nodes: Nodes the size of peanuts can be palpated under the submaxillary, with smooth surface, no tenderness, good mobility and no adhesion. Head and face: skull: skull is normal without deformity, tumor and tenderness, hair density, color and distribution are normal, without furuncle, tinea and scar.
eyes: eyebrows, eyelashes, eyelids and eyeballs are normal, conjunctiva is slightly congested, sclera is free of yellow staining, cornea is clear, and both pupils are equally round, with a diameter of 2.5mm, which is sensitive to light. Ear: The auricle is normal without deformity, the external auditory canal is unobstructed, there is no abnormal secretion, the mastoid process is tenderness, and the hearing is normal.
nose: no deformity, middle nasal septum, no perforation, no turbinate hypertrophy or obstruction, no abnormal secretion of nasal cavity, no tenderness of paranasal sinuses and normal sense of smell. Oral cavity: red lips, no herpes, chapped or ulcer, normal teeth, no bleeding or swelling of gingiva, no herpes, bleeding or ulcer of oral mucosa, pharyngeal congestion (+++), swollen bilateral tonsils II, and middle palate.
neck: shape: symmetrical, no abnormal mass. State: no resistance to rigidity and tenderness, no limitation of activities.
trachea: centered. Thyroid gland: no swelling or nodules.
cervical pulse: no abnormal pulsation and murmur, no jugular vein distension, no hepatocervical reflux sign. Chest: Thoracic: symmetrical appearance, no deformity, normal intercostal space, no local uplift, depression, tenderness and percussion pain, no edema, subcutaneous emphysema and lump, and no venous distension and abnormal reflux.
***: normal size, no redness and tenderness. Lung: Breathing is normal, bilateral respiratory activity is normal, voice quiver is normal, both lungs are palpated with unvoiced voice, and the movement of lung liver voiced boundary, lower lung boundary and lower lung boundary is normal during breathing.
Breathing sounds in both lungs are clear, dry and wet rales are not heard in both lungs, and voice conduction is normal. No pleural fricative sound and wheezing sound.
Heart: The apical beat is located .5cm in the middle line of the left clavicle between the 4th and 5th intercostals. There is no negative apical beat and diffuse beat in the precordial area, no tremor or friction, and the left and right voiced boundaries of the heart are as shown on the right. The heart beat rhythmically, the heart rate was 92 beats/min, the heart sounds were normal, and no pathological murmur was heard in the auscultation area of each valve.
The frequency and rhythm of blood vessel: artery: radial artery are regular and normal, and there is no strange pulse. There is no snapping sound in femoral artery and brachial artery.
Peripheral blood vessels: no capillary pulsation sign, no gunshot sound, no water pulse, no abnormal arterial pulsation, Duroziez's sign (-). Abdomen: Visual diagnosis: the abdomen is symmetrical, the size is normal, the respiratory movement is normal, there is no swelling, depression, rash, pigmentation, stripes, scars, umbilical hernia, varicose veins and gastrointestinal peristalsis waves.
palpation: the abdomen is soft, and there is no tenderness or rebound pain. Do not refuse to press it. Percussion: drum sound, no movable voiced sound and lump.
auscultation: the bowel sounds are normal, there is no breathing, no vascular murmur. Liver: no touch under the rib, no tenderness in the liver area.
gallbladder: untouched, no tenderness in gallbladder area. Spleen: untouched, no tenderness in spleen area.
kidneys: both kidneys have no percussion pain and no waist pain. Bladder: untouched, ureter without tenderness point.
two yin and excrement: two yin: before and after two yin is normal. Excrement: not checked.
Spine limbs: Spine: physiological curvature exists, without deformity, rigidity and tenderness, without limitation of motion, and without tension and tenderness of bilateral muscles. Limbs: Muscle strength and muscle tension are normal, without trauma, fracture and muscular atrophy.
There is no swelling, pain, tenderness, effusion and dislocation in the joint, normal mobility, no deformity, no edema and varicose veins in the lower limbs. Fingernails: Fingernails are ruddy, shiny and normal in shape.
nervous system: sensation: pain, temperature, touch, tuning fork vibration and joint position are all normal. Exercise: no muscle tension and atrophy, no paralysis, no abnormal movements, normal exercise and gait.
shallow reflex: abdominal wall reflex and plantar reflex are normal, but testis-lifting reflex and * * * reflex are not checked. Deep reflex: Second, triceps reflex, radial membrane reflex, knee tendon reflex and achilles tendon reflex are normal.
pathological reflex: hoffmann (-), babinski (-), Gordon (-), chaddock (-), kernig (-). Laboratory examination: blood analysis: WBC 12.6x1e9/L, GRAN%76.2%.
Chest X-ray showed that both lungs and bronchi were infected. Syndrome differentiation basis: four diagnoses combined with reference, this disease belongs to the category of "cough" in Chinese medicine, and the syndrome belongs to "wind-heat type"
The infants are young and have lung qi. 3. what is the medical record style composition (with examples) fast
medical record style. This is a writing style in which doctors write medical records for patients and write articles. It is characterized by novel form, humorous language and eclectic structure. It can be used to criticize the current disadvantages, expose the insider and express the chest. However, it can also be used if you want to take the exam. Because the medical record is too far away from our students' life after all. The name of Wang Xiaocheng's medical report: Wang Xiaocheng Gender: Male Occupation: Student Case: My parents complained that I was five years old. One afternoon, my mother gave Wang Xiaocheng a big, red apple. A classmate said that he was willing to exchange his big porcelain cat for an apple, but he forgot to bring it. He promised to bring it the next day, and the patient gave it to that classmate. The next day, the patient asked for it. The patient was also beaten. Diagnosis: a typical new disease at the beginning of this century-incomplete mind. Opinions: Parents should teach their children more profound skills of getting involved in the world. In view of the young patient, they can teach some basic methods of navigating the rudder according to the wind first. Prescription: smart mind, 5 boxes. Bunao Zengzhi oral liquid, 7 boxes. At the beginning of getting involved in the world (for children), Fang and Yuan. The patient was stumped by a difficult problem. At this time, a paper ball flew to the patient's feet, and Xiao Ling, a friend on the aisle, squeezed his eyes. The patient picked up the paper ball and looked at it, which was just the answer to "getting in the way". The patient did not hesitate to report Xiao Ling's answer. As a result, Xiao Ling was punished, and the patient was beaten again. Diagnosis: the mental handicap was seriously aggravated. Opinions: Parents should teach by example and be tactful. Parents had better take patients to participate in "exercise" in the society during the summer vacation. Prescription: 5 boxes of brain-smart, 8 boxes of brain-nourishing and intelligence-enhancing oral liquid, Introduction to Seeking Advantages and Avoiding Disadvantages, and Prescription and Circle. Three patients complained: 17-year-old, sophomore in high school. The patient went home on holiday, and the Lu Yu car robber, in full view, bravely caught the thief alone and suffered many knife injuries. It is suggested to take a clever daughter-in-law. (Take honesty as the topic or environment as the topic.) Comments: The form of case diagnosis is humorous. The three medical records represent the preschool, primary and middle school periods respectively. Wang Xiaocheng treats people with honesty and integrity, but he is blocked everywhere. The more honest he is, the more unlucky he is, so he is diagnosed as "a typical new disease at the beginning of this century-mental disability." . 4. What is a medical record composition?