(2) Page setup

(3) Layout requirements

(4) medical record paper style

Method of making samples

Introduction to electronic diseases

(1) Header, Footer and Key Points of Making Electronic Case Template

Using Word as an editor to make a medical record template should meet the requirements of medical record writing in the fourth edition of "Operating Routine of Internal Medicine Nursing Technology".

① The common format of the header is "name, department, bed number and medical record number". Some hospitals also include "medical record continuation page" and "medical record paper", and there is no unified regulation at present. In order not to stagger the contents of the header back and forth when actually inputting the contents, it is necessary to establish a table in the header, and frame the name, patient, bed number and medical record number in the table, leaving corresponding spaces, so that doctors can fill in the patient's name and other contents when writing medical records. Pay attention to leave enough space to avoid wrong lines.

(2) The form settings should be automatically formatted with the form provided by Word, and the printed form structure is not displayed, so that the medical record is beautiful and generous. When designing a medical record, there is an input line at the bottom of the table, which cannot be deleted, so as to leave an appropriate space between the header and the medical record content.

(3) The footer should include the name and page number of the hospital, and should generally be designed according to the requirements of each hospital.

(2) Key points of content design of electronic case template.

① The template content in the admission record should include "general items, chief complaints, current medical history" and so on. The case begins with the "Admission Record", and a table is made below. The first six items are one column, leaving a corresponding column. The table in the middle is designed in four columns and six rows. Automatically apply the meshless format to the table provided by word, and adjust the appropriate column width to make the column width have enough space to input the project content. In this way, the items made are arranged neatly, and the input content will not be wrong.

② List the chief complaint, current medical history, personal history, family history, physical examination and other items together, and then set the order of writing the whole case in the case template.