Question 1: How to write a good in-hospital consultation order Summary: The consultation order is an invitation for doctors from other departments to come to study together and discuss the diagnosis and treatment of the patient. It is a discussion of difficult cases. An important component of documentation and complete medical records. Carefully writing the consultation form has certain clinical significance. The basic quality of a doctor and his understanding of the disease can be seen from the writing of the consultation form.

Question 2: How to write the consultation form for lumbar disc herniation? The patient was admitted to the hospital for the main reason (...), and the admission examination (XXX) showed: lumbar disc herniation. Add the patient's relevant chief complaints or physical examination results, and finally add a sentence asking your department to assist in diagnosis and treatment. Thank you! That’s it

Question 3: How to write the consultation record in the disease course record, the patient’s age and gender, why he was admitted to the hospital for consultation, and the auxiliary examination and consultation suggestions

Question 4: How to write the consultation record in the dental department Write the chief complaint, current history, past history, examination, auxiliary examination, diagnosis, and treatment. Just fill in each item

Hope it is adopted

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Question 5: Acupuncture Department How to write the consultation receipt: Patient’s name: Gender: Age: Hospital number: Consultation department: Consulting physician: Consultation process (brief medical history, diagnosis and treatment and treatment process) Medical history: Diagnosis and treatment: Prognosis: Consulting physician’s signature: Year, month and day

Question 6: How to write the TCM consultation record? It is the diagnosis of traditional Chinese medicine plus the format of Western medicine medical records!

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Outpatient medical records

(1) The cover content of the outpatient medical records must be filled in carefully item by item. The patient's name, gender, age, work unit or address, clinic number, and public (private) fees should be filled in by the registration office. X-ray film number, electrocardiogram and other special examination number, drug allergy status, hospitalization number, etc. must be filled in by the doctor.

(2) The medical records of newly diagnosed patients should contain the "five-one signatures

" (chief complaint, medical history, physical examination, preliminary diagnosis, treatment opinions and physician's signature). Among them: ①Medical history should include current medical history, existing medical history, and personal history related to the disease, marriage, menstruation, childbirth history, family history, etc.

②The physical examination should record the main positive signs and negative signs with differential diagnosis significance. ③ List the names of the initially determined or most likely disease diagnoses in separate rows, and try to avoid using words such as "to be investigated" and "to be diagnosed". ④ The handling opinions should list the drugs and special treatment methods used, further examination items, daily life precautions, rest methods and duration; if necessary, record the outpatient appointment date and follow-up requirements, etc.

(3) Return-examination patients should focus on recording the diagnosis and treatment results and disease evolution since the previous visit; the physical examination can be more focused, and the last positive findings should be re-examined, and new findings should be noted. Physical signs; supplement necessary auxiliary examinations and special examinations. For patients who cannot be diagnosed three times, the treating physician should ask a superior physician for examination. For diseases that are different from the last time, outpatient medical records will be written as newly diagnosed patients.

(4) The date of each visit should be filled in, and emergency patients should fill in the specific time.

(5) When requesting consultation from other departments, the purpose, requirements and preliminary opinions of the undergraduate department should be clearly filled out in the medical record and signed by a senior physician of our hospital

.

(6) The invited consulting physician (a senior physician in our hospital) should fill in the examination findings, diagnosis and treatment opinions in the consultation medical record.

(d) When outpatients require hospitalization for examination and treatment, the doctor shall fill in the hospitalization certificate.

(8) Outpatient physicians should be responsible for filling in medical record abstracts for referred patients.

(9) Notifiable infectious diseases should indicate the epidemic reporting situation

Question 7: How to write medical history on anesthesia consultation form

Physical examination-related auxiliary examinations

Recommendation: Can I tolerate surgery? Are anesthesia and surgical risks explained in detail to the patient’s family?

Improve certain aspects of preoperative examination? Preparing blood before surgery? Wait~

Question 8: Nursing consultation record sample 5 points Go to the following website to see if there is any reference:

wenku.baidu/...0&od=0

Question 9: The format of consultation record nursing is different in each acupuncture department

Question 10: How to write the nursing consultation record in the operating room? Surgical cooperation 1, anesthesia method 2, *** 3, instruments and Preparation of supplies 4. Cooperation of circulating nurses 5. Cooperation process of instruments and nurses 6. Precautions 7. Individual surgeons’ habits.