1. General items: name, gender, age, marriage, nationality, occupation, birthplace, current address, work unit, ID number, postal code, telephone number, admission time, recording time, and medical history narrator (indicate reliability). Requirements: (1), write "year" for age, "month" or "day" for infants, but not "cheng", "zi" and "Lao". (2), occupation should specify specific types of work, such as lathe workers, unemployed people, teachers, trade union cadres, etc. , can't be written as ordinary workers and cadres. (3), address: rural township, village, city address; The factory wrote; Workshops, teams and groups, and organs should define departments. (4), admission time, record the time to indicate a few minutes. (5) Narrator of medical history: adult patients narrate themselves; A child or a person who is insane should specify the name of the plaintiff and the relationship with the patient.
2. Chief complaint: (1). Chief complaint refers to the main symptoms, signs, occurrence time, nature or degree, location, etc. The first diagnosis can be based on the chief complaint. The language of the chief complaint should be concise and clear, generally no more than 20 words. (2) Do not take the diagnosis or examination results as the chief complaint (unless there are no symptoms). When there is more than one chief complaint, it can be listed in order of priority or occurrence time.
3. Current medical history: The current medical history is the main part of the medical history. Around the chief complaint, according to the order of symptoms, the occurrence, development, change, diagnosis and treatment of the disease from onset to treatment were recorded in detail. Its contents mainly include: (1), onset time, priority, possible causes and incentives (including some situations before onset if necessary). (2) Time, location, nature, degree and evolution of main symptoms (or signs). (3) With the characteristics and changes of symptoms, important positive and negative symptoms (or signs) with differential diagnosis significance should also be explained. (4) For those who have chronic diseases or relapse related to this disease, we should focus on their initial situation, major changes and recent recurrence. (5), where since the onset of what kind of diagnosis and treatment (including date of diagnosis and treatment, test results, drug name and dosage, usage, surgical methods, curative effect, etc. (6) Other important injuries that have nothing to do with the unhealed disease of undergraduate course but still need to be treated should be described in another article. (7) General conditions since the onset, such as changes in spirit, appetite, appetite, sleep, defecation, physical strength and weight.
4. Past history: Past history refers to the patient's health status and illness before the onset of the disease, especially the diseases closely related to the current disease, which are recorded in chronological order. Its contents mainly include: (1), past general health status. (2), whether suffering from infectious diseases, endemic diseases and other diseases, the date of onset and diagnosis and treatment. For the diseases that patients have suffered before, you can use the name of the disease, but you should add quotation marks; If the diagnosis is uncertain, briefly describe its symptoms. (3), whether there is a history of vaccination, trauma, surgery, and drug, food and other contact allergies.
5. Systematic review: Inquiring about possible diseases in detail according to various systems of the body can help doctors to know briefly whether there is a causal relationship between the diseases that have occurred in a certain system and this chief complaint in a short time, which is an essential part of standardizing medical records. Systemic diseases other than current medical history should also be recorded. (1), respiratory system: chronic cough, expectoration, hemoptysis, chest pain, asthma, etc. (2) circulatory system: whether there are palpitations, shortness of breath, cyanosis, edema, chest pain, syncope, hypertension, etc. (3) Digestive system: Whether there is any history of appetite change, belching, acid regurgitation, abdominal distension, abdominal pain, diarrhea, constipation, hematemesis, melena and jaundice. (4) Urogenital system: Whether there is a history of frequent micturition, urgency, dysuria, hematuria, dysuria, low back pain, edema, etc. (5) Hematopoietic system: whether there is fatigue, dizziness, bleeding spots on skin or mucosa, ecchymosis, recurrent nosebleeds, gingival bleeding, etc. (6) Endocrine system and metabolism: fear of cold, fear of heat, hyperhidrosis, abnormal appetite, emaciation, dry mouth, excessive drinking and diuresis, and changes in personality, weight, hair and secondary sexual characteristics. (7) Nervous system: whether there is a history of headache, dizziness, insomnia, lethargy, disturbance of consciousness, convulsion, paralysis, convulsion, personality change, visual impairment, abnormal sensation, etc. (8) Musculoskeletal system: whether there is any history of limb muscle numbness, disease, spasm, atrophy and paralysis, joint swelling and pain, dyskinesia, trauma and fracture.
6. Personal history: (1), place of birth and time, growth and residence (especially in key epidemic areas and epidemic areas), education level and hobbies. (2), living habits, health habits, eating rules, tobacco and alcohol hobbies and their intake, whether there are other heterosexual and narcotic drug intake history, whether there is a history of major mental trauma. (3), past and present occupation, labor protection and working environment. Focus on understanding whether the patient has a history of frequent contact with toxic and harmful substances, and should indicate the time and degree of contact. (4), whether there is a history of swimming, whether you have suffered from chancre and gonorrhea. (5) For children, before birth, we should not only know the mother's pregnancy and delivery process (natural delivery and dystocia), but also know the feeding history and growth and development history.
7. Marriage history, menstruation, birth history: (1), whether married, age of marriage, health status of spouse, and whether relatives are married. If the spouse dies, the cause and time of death shall be stated. (2) The menstrual conditions of female patients, such as menarche age, menstrual cycle, menstrual days, last menstrual date, amenorrhea date or menopausal age, are recorded in the following formats: menarche age, menstrual cycle (days)/menstrual cycle, last menstrual time (or menopausal age), menstrual volume, color, dysmenorrhea and leucorrhea (quantity and characteristics). (3), married women's pregnancy parity, delivery times, whether there is abortion, premature delivery, stillbirth, surgical delivery, puerperal fever history, family planning, etc. Male patients with reproductive system diseases.
8. Family history: (1), health status of parents, siblings and children, whether there are diseases similar to those of patients, and whether there are diseases related to heredity. The deceased should indicate the cause of death and time. (2) For familial hereditary diseases, it is necessary to ask about the health and diseases of the second-degree and third-degree relatives (see Annex 1). (2) Physical examination Physical examination must be carried out carefully, in the order of parts and systems, with key points and no missing positive signs. Treat patients kindly and seriously, pay attention, be gentle, pay attention to patients' reaction, and keep warm in cold weather. For critically ill patients, we can focus on examination first and rescue them in time, and then do detailed examination after the condition is stable; Don't move too much, so as not to aggravate the illness. Its specific contents are as follows: 1, vital signs: body temperature (T)(C), pulse rate (p) (times/minute), respiratory frequency (r) (times/minute), blood pressure (BP)(kPa).
2. General situation: development (normal and abnormal), nutrition (good, moderate and bad), posture (autonomous, passive, forced or uneasy), gait, face and expression (acute and chronic diseases, painful expressions, anxiety, fear and quietness), consciousness (clear, vague, sleepy and coma), and cooperation with doctors.
3. Skin and mucous membrane: color (flushing, cyanosis, pallor, yellow staining, pigmentation), temperature, humidity, elasticity, presence or absence of edema, rash, ecchymosis, subcutaneous nodules or lumps, spider nevus, ulcers and scars, hair distribution, etc. If yes, the location, scope (size) and shape should be described.
4. Lymph nodes: whether there is swelling (location, size, number, tenderness, hardness, mobility, fistula, scar, etc.). ) in systemic or local superficial lymph nodes.
5. Head and its organs (1), skull: size, shape, tenderness, lump, hair (number, color, distribution, baldness, alopecia areata). The baby should record the size, fullness or depression of the anterior fontanel. (2) Eyes: vision (check if necessary), eyebrows (fall off and become thinner), eyelashes (trichiasis), eyelids (edema, movement and drooping), eyeballs (protrusion, depression, movement, strabismus and tremor), conjunctiva (congestion, bleeding, pallor and edema), sclera (yellow staining) and sclera (yellow staining). (3) Ear: hearing, presence of deformity, secretion and tenderness of mastoid process. (4) Nose: whether there is deformity, alar flap, secretion, bleeding, obstruction and tenderness in the paranasal sinus area. (5) Oral cavity: bad breath, saliva secretion, lips (deformity, discoloration, herpes, chapped, ulcer, angular deviation), teeth (dental caries, missing teeth, dentures, residual roots, such as: dental caries 3+4), gums (discoloration, swelling, exudation, bleeding, etc.).
6. Neck: symmetry, stiffness, jugular vein dilatation, hepatojugular vein reflux sign, abnormal pulsation of carotid artery, lump, trachea position, thyroid gland (size, hardness, tenderness, nodule, tremor, murmur, up-and-down mobility during swallowing).
7. Chest: (1), thorax (symmetry, deformity, local uplift or collapse, tenderness), breathing (frequency, rhythm and depth), abnormal pulsation and varicose veins. Breast diseases are described according to the requirements of breast examination. (2) Lung: Visual diagnosis: respiratory movement (bilateral comparison), respiratory type and whether the intercostal space is widened or narrowed. Palpation: Trembling speech, feeling of pleural friction and subcutaneous torsion. Percussion sound: Percussion sound (unvoiced sound, voiced sound, solid sound, unvoiced sound or drum sound), lower lung boundary and lower lung boundary activity. Auscultation: Breathing sounds (nature, strength, abnormal breathing sounds), dry and wet rales and pleural friction sounds, voice conduction (pay attention to symmetrical parts), etc. (3) Heart: Visual diagnosis: apical pulsation (position, range, intensity) with unintentional anterior region uplift. Palpation: apical pulsation (nature, location, range and intensity), tremor (location and duration) and pericardial fricative sound. Percussion: The left and right voiced boundary (relative voiced boundary) of the heart is represented by the distance from the rib to the midline, and the distance from the midline of the clavicle to the anterior midline is represented by a table (Table 1). Auscultation: heart rate, heart rhythm, heart sounds (intensity, division, comparison between P2 and A2, extra heart sounds, galloping rhythm) and whether there are murmurs (position, nature, period, intensity, conduction direction) and pericardial fricative sounds. Right (cm) intercostal left (cm) Ⅱ Ⅲ Ⅴ Ⅴ The clavicle midline is cm away from the anterior midline.
8. Vascular examination: (1), radial artery: pulse rate, rhythm (regular or irregular, short pulse), presence or absence of odd pulse and alternating pulse, pulse comparison between left and right radial arteries, nature and tension of arterial wall. (2) Peripheral vascular signs: whether there is capillary pulsation, sound emission or water pulse.
9. Abdomen: (1), optic nerve rash: appearance (symmetry, flatness, swelling and depression), respiratory movement, umbilicus, presence or absence of rash, stripes, scars, lumps, varicose veins (if any, record the blood flow direction), gastrointestinal peristalsis waves, and upper abdominal pulsation. (2) Palpation: Abdominal wall: abdominal wall tension, tenderness, rebound pain, liquid wave tremor, mass (position, size, shape, hardness, tenderness, pulsation and mobility). Abdominal circumference should be measured when there is ascites or abdominal mass. Liver: size (the right lobe is indicated by the number of centimeters from the midline of the right clavicle to the lower edge of the liver, and the left lobe is indicated by the number of centimeters from the xiphoid process to the lower edge of the left lobe of the liver), texture, surface, edge, tenderness and pulsation. Gallbladder: size, shape, tenderness or not Spleen: size, hardness, surface, marginal state, tenderness or not. The giant spleen is represented by three lines. Kidney: size, shape, hardness, mobility, tenderness of renal area and ureter tenderness point, bladder swelling. (3) Percussion: liver dullness, whether there is percussion pain in the liver area, moving dullness, high drum sound, and percussion pain in the kidney area. (4), auscultation: bowel sounds (normal, enhanced, weakened or disappeared), whether there is vibration sound, vascular murmur.
10, anorectal: presence of hemorrhoids, anal fissure, rectocele and anal fistula. Attention should be paid to anal sphincter tension, stenosis, internal hemorrhoids, tenderness, prostate size and hardness during anal digital examination; Pay special attention to whether there are palpable masses (size, location, hardness, activity, etc.). ). Pay attention to the color of the finger cover when exiting the finger test.
1 1, external genitalia: make corresponding examination according to the condition. (1), male: pubic hair distribution, presence or absence of developmental deformity, penis scar, urethral secretion, foreskin, testis, epididymis, spermatic cord, varicocele, hydrocele of tunica vaginalis. (2) Female: Please have a gynecological examination if necessary. Male doctors must be accompanied by female medical staff.
12, spine and limbs: (1), spine: deformity, tenderness, percussion pain, mobility. (2) Limbs: presence of deformity, clubbed fingers (toes), varicose veins, fractures, edema, muscular atrophy, limb paralysis or increased muscle tension, and joints (redness, swelling, pain, tenderness, effusion, dislocation, limited movement and rigidity).
13, nervous system: (1), physiological reflex: corneal reflex, abdominal wall reflex, testicular lifting reflex, biceps brachii reflex, triceps brachii reflex, knee tendon reflex, achilles tendon reflex. (2) Pathological reflex: babinski's sign, etc. (3) Meningeal irritation signs: neck rigidity, Brudzinski sign and Keniger sign. (4), when necessary, do exercise, sensory and other nervous system examination. 14. Specialized information: record special information of specialized diseases, such as surgery, ophthalmology, gynecology, etc. (See the writing points of medical records of various specialties).
(3) Laboratory and instrument inspection: record the laboratory and instrument inspection results related to diagnosis. If the examination is conducted before admission, the place and date of the examination should be indicated.
(4) Summary: Summarize the comprehensive medical history, physical examination, laboratory examination, instrument examination and other major data, highlight the positive findings, and prompt the diagnosis basis.
(5) Preliminary diagnosis: write it on the last right side of the medical record. According to primary diseases and secondary diseases, diseases related to the chief complaint or life-threatening diseases rank first. In addition to the full name of the disease, the diagnosis should also include the diagnosis of the etiology, anatomical location and function of the disease as far as possible.
(6) Admission diagnosis: The attending physician makes the admission diagnosis within 72 hours after the patient is admitted to the hospital. Write it in red ink in the last left half of the medical record (the same height as the first diagnosis), mark the date of diagnosis and sign it.
(7) Signature of medical record reviewer: The signature should be written on the lower right of the last medical record. Draw a diagonal line above the signature, so that the superior doctor can sign it after reviewing and modifying it. 1, the cover content of outpatient medical records should be carefully filled in item by item. Fill in the patient's name, gender, age, work unit or address, outpatient number and public (self) fee from the registration room. X-ray number, electrocardiogram and other special inspection numbers, drug allergy, hospitalization number, etc. It should be filled out by a doctor.
2. The medical records of newly diagnosed patients should include "five signatures" (chief complaint, medical history, physical examination, preliminary diagnosis, treatment opinions and doctor's signature). Among them: ① Medical history should include present medical history, past medical history, personal history related to the disease, marriage, menstruation, birth history, family history, etc. ② Physical examination should record the main positive bodies and negative signs with differential diagnosis significance. (3) List the names of diseases that are initially diagnosed or most likely, and try to avoid using words such as "to be investigated" and "to be diagnosed". (4) The treatment opinions should list the drugs used and special treatment methods, further examination items, matters needing attention in life, rest methods and time limit; If necessary, record the appointment date and follow-up requirements.
3. Follow-up patients should focus on the diagnosis and treatment results and the evolution of the disease after the previous follow-up; Physical examination can focus on the last positive discovery and the newly discovered signs; Supplementary necessary auxiliary inspection and special inspection. For patients who cannot be diagnosed for three times, the attending doctor should ask the superior doctor for consultation. For diseases different from last time, all outpatient medical records should be written according to newly diagnosed patients.
4, each visit should fill in the date of visit, emergency patients should fill in the specific time.
5. It is required that the purpose, requirements and preliminary opinions of the undergraduate course should be clearly filled in the medical records and signed by senior doctors in our hospital.
6. Invited consultants (senior doctors in our hospital) should fill in the examination results and diagnosis opinions on the consultation medical records for instructions.
7. If the outpatient department needs hospitalization examination and treatment, the doctor shall fill in the hospitalization certificate.
8. The outpatient physician is responsible for filling in the medical record summary of the referred patient. 9, the legal epidemic situation report of infectious diseases should be indicated.