Writing of current medical history:
Before (time), the patient had no obvious inducement (suspected to be due to xx) (symptoms), and described the characteristics of symptoms (location, nature, degree, duration, frequency, aggravating and relieving factors, posture relationship). The condition evolved with xx (accompanied by symptoms and their characteristics). There is xx, but there is no xx, xx (a negative symptom with differential significance).
After the diagnosis and treatment, instead of writing that the patient (on time) went to xx hospital for diagnosis and treatment, he did xx examination, showing xx (examination results), xx drug treatment (whether it was in accordance with the doctor's advice), and the curative effect was average (the symptoms did not relieve). In order to make further diagnosis and treatment in the outpatient/emergency department of our hospital, hospitalized patients with medical records will undergo xx examination, showing xx (examination results), and it is proposed to include "xx" in our department. General description: since the onset, the patient's spirit, sleep, stomach and urine are all normal, and his weight and physical strength have not changed significantly.
Remarks:
1. Time should be in Arabic numerals, such as 3 days and 2 years.
2. Symptoms should be written from head to toe, and at most three of them should be written together, such as no acid reflux, heartburn and belching. It is suggested to put the same type together.
3, the patient's own description of the examination, surgery, results, etc. Need to use ""(the same is true of past history).
4, the development of the disease, such as: 1 I can climb five floors a week ago, and now I can only climb two floors.
5. Write down the current medical history in chronological order. If the patient's condition gets worse, write a description of the patient's characteristics in xx. If the negative symptoms are consistent/except the symptoms, the negative symptoms are the same as before and the positive symptoms are the same.
6. After the diagnosis and treatment, the patient may not know the dosage of the drug, so he wrote it (details are unknown). I've seen both bracketed and non-bracketed, and I'm used to brackets.
7. In writing the current medical history, I personally think that the biggest difficulty that may be encountered is the description of symptom characteristics, because it says that I found that I forgot to ask this, I forgot to ask that, and it is easy to forget to ask differential symptoms.
8. The current medical history revolves around the chief complaint, which has nothing to do with it, such as hypertension (note: if there is a relationship, hypertension should also be put up).
Examples of writing current medical history:
Chief complaint: bloody stool and hematemesis for 3 days.
Current medical history: The patient suspected bloody stool three days ago due to fever, with dark red and thin stool, 1 day, about 200ml for five times, red hematemesis 1 time in the middle, and stomach contents in the blood, about 300ml, accompanied by abdominal distension above navel. The patient is pale, dizzy, weak, thirsty, palpitation, acid reflux and decreased urine output. No oral ulcer, headache, unconsciousness, cough, expectoration, shortness of breath, chest tightness, chest pain, heartburn, belching and internal urgency.
For further diagnosis and treatment, the patient came to our hospital for emergency treatment on 1 day, made a "blood routine", showing "Hb 103g/L", and planned to be admitted to the hospital for "gastrointestinal bleeding". Since the onset, the patient has lost appetite and spirit, can sleep and defecate as mentioned above, and has no obvious changes in weight and physical strength.