1. The patient's medical history and physical examination: record the patient's medical history and physical examination in detail, including injuries, injured parts, bleeding and so on.
2. clinical diagnosis: according to the patient's medical history and physical examination, the clinical diagnosis results are given.
3. medical advice and attention phenomena: according to the clinical diagnosis results, medical advice and attention phenomena are given, including treatment schemes and possible complications.
4. doctor's signature: a doctor should sign when making a diagnosis, and keep his signature for the record.
5. issuing time: the doctor should issue the time to prove the timeliness of the diagnosis results.