Legal basis: Article 18 of the Basic Specification for Medical Records Writing: Requirements and contents of admission records;
(1) The general information of patients includes name, gender, age, nationality, marital status, birthplace, occupation, admission time, recording time and medical history statement.
(2) Chief complaint refers to the main symptoms (or signs) of patients and the duration of treatment.
(three) the current medical history refers to the details of the occurrence, evolution, diagnosis and treatment of the patient's disease, which should be written in chronological order. The contents include the incidence, the characteristics and development of main symptoms, accompanying symptoms, the course of disease and the results of diagnosis and treatment after onset, changes in general conditions such as sleep and diet, and positive or negative data related to differential diagnosis.
1. Incidence: record the time, place, priority of onset, precursor symptoms, possible causes or incentives.
2. Characteristics and development of main symptoms: describe the location, nature, duration, degree, relieving or aggravating factors, evolution and development of main symptoms in order of occurrence.
3. Accompanying symptoms: record accompanying symptoms and describe the relationship between accompanying symptoms and main symptoms.
4. Diagnosis and treatment process and results since the onset: record the detailed process and effect of examination and treatment in and out of the hospital from the onset to admission. Names of drugs, diagnosis and operation provided to patients should be marked with quotation marks ("") to distinguish them.
5. General situation since the onset: briefly record the patient's mental state, sleep, appetite, defecation and weight after the onset.
Other diseases that are not closely related to this disease but still need treatment can be recorded in another paragraph after the current medical history.
(4) Past history refers to the patient's past health and illness. The contents include general health status, disease history, infectious disease history, vaccination history, surgical trauma history, blood transfusion history, food or drug allergy history, etc.
(5) Personal history, marriage and childbearing history, menstrual history and family history.
1. Personal history: record the birthplace and long-term residence, living habits, hobbies such as alcohol, tobacco and drugs, occupation and working conditions, contact history of industrial poisons, dust and radioactive substances, smelting and travel history.
2. Marriage and childbearing history, menstrual history: marital status, marriage age, spouse's health status, children, etc. Female patients recorded menarche age, menstrual period days, interval days, last menstruation (or amenorrhea age), menstrual flow, dysmenorrhea and delivery.
3. Family history: the health status of parents, brothers and sisters, whether there are diseases similar to the patients, and whether there are diseases with family genetic tendency.
(6) Physical examination writing should be systematic and orderly. The contents include temperature, pulse, respiration, blood pressure, general condition, skin, mucosa, superficial lymph nodes, head and its organs, neck, chest (chest, lung, heart, blood vessels), abdomen (liver, spleen, etc. ), rectum and anus, external genitalia, spine, limbs, nervous system, etc.
(seven) the special circumstances of the profession should be recorded according to the needs of the profession.
(eight) auxiliary examination refers to the main examination and its results related to this disease before admission. Inspection results shall be recorded in the order of inspection time. For inspection in other medical institutions, the name and inspection number of the institution shall be stated.
(9) Preliminary diagnosis refers to the diagnosis made by the attending physician according to the comprehensive analysis of the patient when he is admitted to the hospital. If the initial diagnosis is multiple, the priority should be clear. Cases to be investigated should list more likely diagnoses.
(ten) the signature of the doctor who wrote the admission record.