1. Visiting time and department: First of all, the visiting time and department should be clearly recorded in the visiting results so as to determine the specific situation.
2. Complaint and medical history: Next, describe the patient's complaint and medical history in detail, including the starting time, nature and changes of symptoms, so that doctors can fully understand the patient's condition.
3. Physical examination and auxiliary examination results: record the physical examination results of patients, including vital signs and physical characteristics. In addition, it is also necessary to record the auxiliary examinations carried out by patients, such as blood tests and imaging examinations, so that doctors can comprehensively evaluate the patient's condition.
4. Diagnosis: The doctor will give the corresponding diagnosis according to the patient's medical history, physical examination and auxiliary examination results, including the name and type of the disease.
5. Treatment suggestions: According to the diagnosis results, the doctor will give corresponding treatment suggestions, including drug treatment, surgical treatment and rehabilitation training.
6. doctor's signature: finally, the doctor needs to sign the medical results to ensure the authenticity and reliability of the medical results.