July, 2009-17xx, the attending physician made rounds on the second day after the patient was admitted to the hospital (general situation). Did the general situation (eating, sleeping at night, defecating) have any special circumstances last night? If not, I won't write the physical examination of that day, so don't elaborate on this, right? Each subject has its own emphasis. Then there is the inspection report received before writing the medical record, which is complete and analyzes the anomalies one by one. For meaningless exceptions, we should also explain the reasons for not handling them. Usually, the sentence is "no obvious clinical manifestations support, no treatment for the time being, next review", followed by XX attending physician to analyze the condition and review the medical history after rounds today. XXXX can write the diagnosis basis and useful inspection report of admission. Finally, receive the treatment advice, the doctor's advice changes made that day and the reasons (the reasons can actually be laziness or vagueness, but you should write the doctor's advice changes). Finally, add a sentence, strengthen the observation of the condition, and finally sign it.