(2) Medical history: the current medical history (including the date of onset, main symptoms, diagnosis and treatment in other hospitals and curative effect) should be highlighted, and the past history, personal history and family history related to this disease should be briefly described (there is no need to list problems). (3) Physical examination covers a wide range of situations, focusing on recording positive and negative signs that are helpful for differential diagnosis. (4) Records of laboratory inspection, instrument inspection or consultation. (5) Treatment measures ① The records of prescriptions and treatment methods should be listed according to decay. ② Further inspection measures or suggestions; (3) rest mode and duration. Follow-up visit (1) The words "the condition is the same as before" cannot be used for the change of illness and treatment response after the last diagnosis and treatment. (2) Physical examination: focus on recording the changes of original positive signs and new positive findings; (3) laboratory or instrument inspection items that need to be supplemented. (4) For patients who can't be diagnosed for three times, the attending physician should ask the superior doctor for consultation, and the superior doctor should write down the consultation opinions and the consultation date and time. O(5) Diagnosis: For patients who have been diagnosed last time, if the diagnosis has not changed, there is no need to write the diagnosis o(6). The treatment measures are the same as the initial diagnosis. Patients also write medical records according to the requirements of the initial medical records. Article source: Putian andrology hospital Putian andrology