Native place (province, city and county must be indicated),

Date of admission: In case of emergency or serious illness, the time should be indicated. The year, month and day should be filled in.

Condition: fill in "patient"; If it is described by others, explain the reliability.

2) Chief complaint

● There are two space bars between the main complaint content of electronic medical records and the main complaint. The following subheadings, such as "current medical history", require the same distance from 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 maculopapules all over the body for 3 days".

● It is not recommended to replace symptoms with diagnosis or test results.

● If there is more than one chief complaint, it should be listed separately in the order of occurrence, such as "intermittent empty abdominal pain 1 year, tarry black stool 1 day"; Frequent urination and urgency for 3 hours.

3) Current medical history

● According to the time sequence of symptoms, accurately record the onset date, onset priority, onset inducement, occurrence time and development process of each important symptom. Negative symptoms related to differential diagnosis should also be recorded (with symptomatology and differential diagnosis as the main contents).

When describing symptoms, we should grasp the key points and be systematic. For example, when describing pain, we should make clear the location, time, nature, degree and other related factors of pain, as well as the influence of treatment.

● Ask the accompanying symptoms according to the system to avoid omission.

● Previous examination and treatment.

● If the details of the accident, suicide or murder are related to the illness, they should be recorded objectively and truthfully, and subjective comments or guesses are not allowed.

● Those who still need diagnosis and treatment for important injuries in other departments unrelated to the undergraduate course are described in another article.

4) Past history

● General health is strong or weak.

● Chronological history of acute infectious diseases. Record the occurrence time, treatment results and complications of the disease. If there is no history of infectious diseases, it is necessary to record the infectious diseases that have not occurred related to the current condition for reference. If you have herpes zoster, ask if you have a history of chickenpox.

● Whether you have been vaccinated, its type and the date of the last vaccination.

● Ask about diseases according to the system, including five senses, respiratory system, circulatory system, digestive system, urogenital system, blood system, neuropsychiatric system, motor system (muscles, bones and joints), history of trauma, surgery, 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) Resume

● Pay special attention to the natural foci and epidemic areas of the place of birth and experience, indicate the migration date, and indicate the specific foci or water sources, such as the contact history of blood-sucking diseases in the early stage.

● Living habits include eating habits, alcohol and tobacco hobbies.

● Past and present occupations and their work conditions, including the time of enlistment or work, arms or types of work, positions, contact history with toxic substances, radioactive substances and patients with infectious diseases.

● The menstrual history from menarche to now, the number of days between each menstrual period, the duration of each menstrual period and the age of amenorrhea can be expressed in the following simple ways:

Age of menarche: the number of days per menstrual cycle, the number of days between menstrual cycles, the age of amenorrhea or

Age of menarche (days per menstrual cycle)/age of amenorrhea (days between menstrual cycles) or described in words.

For example: 163 ~ 4 30 ~ 3248 or

Electronic medical records can be described in language or the following formats.

"16Y, (3~5D)/(30~32D), 48Y or 1999, 8, 23."

Attention should also be paid to whether there is pain during menstrual cramps, the amount, color and characteristics of menstruation, and the date of the last menstruation.

● Marital status and production history: When did you get married? Your spouse's health status, if dead, please explain the cause and year of death, whether the delivery is normal, whether there is a 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, you should ask whether there is a history of unclean sexual intercourse.

6) Family history

● Health status of father, mother, brother, sister and children. If dead, explain the cause of death.

● If diseases caused by genetic factors and life contact factors are suspected, 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 information: temperature, pulse, pulse condition, breathing (frequency and depth), blood pressure, height and weight (if necessary); Development (normal, abnormal, poor); Nutrition (good, medium, poor, emaciated, obese); Body position and posture (such as flexion position, tilt position, etc.). ), complexion (such as ruddy and dull, etc. ); Expression (anxiety, pain, chronic diseases); Consciousness (awake, sleepy, semi-coma, coma) and speech state (clear, fluent, answering questions to the point), cooperation during the exam, 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.

● Whether the lymph nodes are swollen in the whole body or in the local area (submandibular, behind the ear, neck, clavicle, armpit, groin, etc.). ), should indicate the size, quantity, hardness, tenderness, adhesion; Whether the local skin has red fever, fistula or scar.

● Head

Skull: size, shape, hair distribution, furuncle, tinea, trauma, scar and lump.

Eyes: fissure size, eyelid and eyeball movement, cornea, conjunctiva, sclera, pupil size and shape, bilateral symmetry, light response, accommodation response, vision (gross measurement), and fundus examination if necessary.

Ear: There is no abnormality in auricle, no secretion in external auditory canal and no tenderness in mastoid process.

Nose: presence of deformity, obstruction, secretion, abnormal nasal septum, unobstructed sense of smell, and sinus tenderness.

Oral cavity: bad breath, lip color, herpes, microvascular pulsation, broken mouth; Whether the teeth have decayed teeth, sloshing, defects, filling teeth, etc. And their locations, such as dental caries, up and down, left and right 55 8, defect 4+, (electronic medical records can be described in language). Whether there is bleeding, pus, atrophy and pigmentation in the gums; Tongue coating, tongue quality, whether there is deflection and tremor when tongue is extended; Whether the oral mucosa has rash, ulcer, false membrane or pigmentation; Size of tonsil, presence of congestion, edema and secretion, presence of congestion, rash and secretion in pharynx, pharyngeal reflex, soft palate movement, whether uvula is centered, and whether swallowing is normal.

Whether the neck is symmetrical, whether the movement is limited, whether there is rigidity, whether there is tenderness, abnormal pulsation, venous dilatation, mass, and whether the trachea is centered. Thyroid shape, size, hardness, presence of nodules, tremor, tenderness, murmur, etc.

● Chest shape, symmetry, fullness or depression between ribs, degree of exercise, size of arch angle, and whether there is edema, subcutaneous emphysema, lump or vasodilation on chest wall. Whether there are tenderness, depression and other abnormalities in ribs and costal cartilage. Breast condition (size, redness, tenderness, lump shape, size and hardness, etc. ).

● Lung

Visual diagnosis: breathing type, speed, depth, symmetry of breathing movement on both sides.

Palpation: whether the two sides of the voice tremor are equal and whether there is a sense of friction.

Percussion: reaction (normal, voiced, solid and drumming), lower lung boundary position and respiratory activity.

Auscultation: Pay attention to the nature of breathing sounds (alveolar sounds, bronchoalveolar sounds, tubular breathing sounds) and their intensity (normal, decreasing, increasing and disappearing), voice conduction, and whether there are fricative sounds, wheezing sounds, dry mouth rales and wet rales.

Note: Positive signs should be described according to the marked coordinates of physical diagnosis.

● Heart

Visual diagnosis: the location and range of apical pulsation, and whether there is abnormal pulsation and swelling in the precordial area.

Palpation: whether there is a lifting impulse, tremor or friction in the part of the apex with the strongest pulsation, and its location, time and intensity.

Percussion: At each intercostal interval, the left and right cardiac boundaries were recorded in centimeters (cm) from the sternal midline. If the left heart boundary exceeds the clavicle midline, the distance beyond it should be recorded in centimeters (cm).

————————————————

Right intercostal left side

————————————————

2 2 2

2 3 3

3 IV 4.5

V 7

_____________________________

Auscultation: heart rate and rhythm. If the rhythm is irregular, the heart rate and pulse rate should be calculated simultaneously. The nature and intensity of heart sounds, unintentional sound splitting, the third and fourth heart sounds, and the intensity of the second sound between aortic valve and pulmonary valve were compared in each valve sound region. Whether there is pronunciation, we should pay attention to the time, intensity, nature, where the noise is the loudest, where it is transmitted, and whether there is unintentional fricative sound.

● Abdomen

Visual diagnosis: respiratory movement, whether the abdominal wall is symmetrical, whether there are depressions, swelling, varicose veins, peristalsis waves or local uplift, and umbilical conditions.

Palpation: the abdominal wall is soft or tense, with or without tenderness, the location and degree of tenderness, refusal or preference for pressure, and rebound pain; Whether there is a mass, its position, size, shape, hardness, tenderness, activity, the influence of respiratory movement, whether there is pulsation and fluctuation, etc.

Liver: Can I touch it? If it can be touched, the number of centimeters (cm) from the lower margin of the liver to the costal margin of the clavicle midline and xiphoid process should be recorded. Pay attention to the sharpness, hardness and tenderness of the liver margin. Pay attention to whether there are nodules on the liver surface when hepatomegaly occurs.

Gallbladder: Touchability, size, tenderness.

Spleen: whether it can be touched. If you can touch it, you should indicate whether the surface is smooth, whether there is notch and tenderness, how hard it is, how many centimeters (cm) it is from the rib edge of the clavicle midline (vertical diameter AB and maximum oblique diameter AC), and the activity of the spleen when lying flat and sideways (Figure-1).

Figure-1 spleen size recording method

(Atlas of human body parts in electronic medical records will be established in the future. )

Kidney: accessibility, size, activity, tenderness, etc.

Percussion: Single boundary of liver and spleen turbidity [the upper boundary is in intercostal space, and the total length is in centimeters (cm)], whether there is percussion pain, excessive echo and flowing voiced sound in liver and spleen area.

Auscultation: intestinal peristalsis sound and its sound quality and frequency, whether there is vibration sound in the stomach area and whether there is friction sound in the liver and spleen area. Whether there is vascular murmur, and record its position and nature.

Low vulva and anus

External genitalia: development, phimosis, urethral secretion, testicular position, size, hardness, enlarged spermatic cord, tenderness, nodules and varicose veins. Whether the scrotum is peeling, chapped and swollen; If swelling occurs, use fluoroscopy to determine whether there is hydrocele in the tunica vaginalis. Female genital examination (see gynecological examination) must be assisted by a female nurse or examined by a female doctor.

Anal: whether there are hemorrhoids, anal fissure, anal fistula, eczema, etc. If necessary, anorectal digital examination or anoscopy should be performed.

● Whether the spine and limbs are deformed, tender and painful; Whether the muscles on both sides of the spine are tense or tender; Whether there is tenderness or percussion pain in the costal ridge angle; Whether there are deformities, clubbing fingers, edema, trauma, fractures and varicose veins in limbs; Muscle tension and muscle strength, whether there is atrophy; Whether the joint is red, swollen, deformed or dyskinesia. Whether there is microvascular pulsation in nail bed; Whether there are gunshots in femoral artery and brachial artery; Radial artery pulsation and vascular hardness.

● Limb movement and sensation of nervous system, knee reflex, Achilles tendon reflex, biceps reflex, triceps reflex, abdominal wall reflex, testicle lifting reflex, babinski's sign, Koenig's sign, etc.

8). Professional information

Such as surgery, gynecology and ophthalmology. , should be focused, detailed, true and systematic description of the relevant signs of each major, see the routine of each major.

9). Inspection and other inspections

Main laboratory tests within 24 hours after admission: routine blood, urine and stool tests, as well as X-ray and electrocardiogram. Important examination results before admission can be recorded in the current medical history.

10) summary

Briefly summarize the main points of medical history, positive test results, important negative results and related test data in about 100~300 words.

At the time of admission, the main injury has been determined and you can write "diagnosis". The initial diagnosis should be based on all the medical history and preliminary examination results, and the existing diseases should be diagnosed through comprehensive analysis and listed by branches. Its order is based on the following principles: the main disease first, then the second disease; The undergraduate disease comes first, and other diseases come last. When there may be more than one main diagnosis, record the most likely one or two. Write the name of the disease first, and then record the type, location and prescription as needed; The diagnosis record is on the right side of the medical record.

1 1). Signature

● After the above medical records are recorded and signed by interns, they will be reviewed by residents, corrected with red ink pen and signed in full name. Handwriting must be correct and clear.