1. According to the query of China Medical Network, the patient information includes basic information such as name, gender, age, height, weight and contact information.
2. Diagnostic information: record the patient's disease type, diagnosis time, diagnosis doctor and other information in detail.
3. Medication suggestion: List the drugs being used by patients and those recommended by doctors, including name, dosage, frequency of use, time of use and other information. New drugs or dressing changes, especially noted.
4. Pharmacist's suggestion: Clinical pharmacists put forward reasonable medication suggestions according to the patient's condition and medication situation, including adjusting drug dosage, changing drug types and preventive use of antibiotics. And the reasons and suggestions are given.
5. Precautions: List the matters that patients need to pay attention to during medication, including monitoring vital signs, paying attention to drug interaction and avoiding adverse reactions.
6. Signature and date: The clinical pharmacist signs and dates at the end of the record to show responsibility and ensure the authenticity and timeliness of the record.