Example of medical record writing ● hospitalized patient ××××, female, 60 years old, married, Han nationality, farmer, now living in XX village, XX county, Hebei province. The main cause of XXX was admitted to the hospital at 9: 00 on May 2000-10. The patient is due to ... 1. respiratory system: fever, chills, cough, hemoptysis, hot flashes, night sweats, dyspnea, thick and smelly sputum (color and quantity), etc. 2. Digestive system: acid regurgitation, heartburn, belching, nausea, vomiting (nature, color and quantity), abdominal pain, diarrhea, acute diarrhea, etc. 3. Cardiovascular system: headache, dizziness, chest tightness, chest pain (duration of attack), wheezing, palpitation, shortness of breath, sweating, etc. 4. Nervous system: speech, limbs, blackness, consciousness, syncope, mental disorders, etc. ..... was diagnosed as "×××××" in the local outpatient department, and was treated with drugs such as ×××× (the specific dosage is unknown), but there was no obvious improvement. Come to our hospital for further diagnosis and treatment. Since the onset of the disease, the general situation can be that the patient has no appetite, sleep and defecation, denies the history of infectious diseases such as hepatitis and tuberculosis, and has no history of surgery, trauma or drug allergy. Born in the country of origin, has lived there for a long time, has never been to an epidemic area or pastoral area, has no addiction to tobacco and alcohol, has a menstrual period of 14(3-5/28)55, is pregnant and has given birth to three children, and has no record of infectious diseases and hereditary diseases in his family. Physical examination showed that TPP developed normally, with moderate nutrition, body position (automatic, sitting, forced, lying), conscious (awake, unclear), and physical examination cooperated. There are no yellow spots, bleeding spots, ecchymosis, spider nevus and subcutaneous nodules on the skin and mucosa of the whole body, no swelling of superficial lymph nodes, no deformity on the head and face, no edema on the eyelids, no yellow spots on the sclera, no conjunctiva (congestion and pallor), round pupils on both sides, reflective (sensitive, dull and disappearing), no abnormality in the ear and nose, no cyanosis on the lips and no congestion on the pharynx. There is no abnormality in the chest, the respiratory movements on both sides are consistent, and the tremor does not increase or decrease. The boundary between lung voiced sound and lung-liver voiced sound is located in the 5th intercostal space of the right clavicle midline. The breathing sounds of both lungs are clear or coarse, and dry and wet rales are audible. There is no swelling in the precordial area, no obvious pulsation at the apex, no tremor, small cardiac boundary, 80 beats/min, regular rhythm, no murmur in the auscultation area of each valve, flat abdomen, no intestinal type and peristalsis wave, soft abdomen, no tenderness and rebound pain, no touch of liver and spleen, no percussion pain in the liver area, negative movement dullness, normal bowel sounds and no anal and rebound pain. Preliminary diagnosis: doctor's signature XX May 2000-10 ● Course record May 2000-/kloc-0, 9: 00 Patient XX, female, 60 years old, main cause XX May 2000-10, 9: 00. According to 1, the patient is an elderly woman. 2. In the past ... 3. The patient was diagnosed and treated for ... 4. Physical examination ... 5. Blood routine, X-ray and CT, and all kinds of auxiliary examinations were further improved. ● Discharge record form: including admission due to …, physical examination, auxiliary examination results and consideration of … hospitalization process: according to the symptoms, signs and auxiliary examination results of patients, the initial diagnosis is: 2. Pay attention to diet. 3. Oral medication. 4. Change the condition and follow up in time. ● The order of discharge medical records is 1. The first page of the medical record is 2. The discharge record is 3. The hospitalization record is 4. The course record is 5. The consultation record is 6. The radiation report form is 7. The electrocardiogram is 8. Gastroscope and B-ultrasound are 9 kinds of test sheets, and B-type test sheet is 10. Treatment records (long-term doctor's advice and temporary doctor's advice) are 1 1. 3. Current medical history [blank 2 boxes ]4. Past and personal history (brief) [blank 2 boxes ]5. T P R BP (if necessary) [blank 2 boxes ]6. Physical examination and auxiliary examination (brief) [blank 2 boxes] 7. Preliminary diagnosis (right) 8. Handling (left) [blank 2 boxes ]9 Signature (signature)