出院病历书写请求合格局(国外英文资料).doc

入院病历书写要求及格式 Admission medical records (commonly referred to as major medical records) for writing requirements and formats 1, the written requirement of admission record (1) the admission medical records (commonly referred to as the major medical records) shall be written by the intern, the probation physician, and the medical personnel registered by the medical establishment to review, revise and sign the medical records. The hospital records should be completed within 24 hours after admission. (3) the medical history and physical examination prior to the admission of the medical records shall be conducted under the guidance of the clinical teachers and the guidance physician. (4) the written requirements and contents of the hospital records are the same as the admission records in principle, with the addition of the medical records and the review of the system (in the past). enterism Name: birthplace: Gender: career: Age: admission date: Nation: record date: Marriage: Main: Now the history: Past medical history: A systematic review Respiratory system: cough, sputum, dyspnea, haemoptysis, fever, night sweats, and close contact with tuberculosis patients. Circulation system: presence of flustered, shortness of breath, hemoptysis, cyanosis, the area before the heart pain, syncope, edema, and a history of high blood pressure, arteriosclerosis, heart disease, rheumatic fever, history, etc. Digestive system: the presence of abdominal pain, abdominal distension, acid regurgitation, belching, vomiting, hematemesis, difficulty swallowing, diarrhea and black history, secret history, history of with and without jaundice itchy skin, and so on. Urinary system: presence of urgency, frequent urination, urinary pain, micturition not free or shower drain, urine color (wash meat samples or soy sauce color), QingZhuo degrees, edema, renal toxicity of drug application history, history of lead, mercury toxic chemical contact or poisoning and chancre, gonorrhea, syphilis and other sex