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. These include:

(1) Medical history should include present medical history, past medical history, personal history related to diseases, 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.

⑤ The medical records written by interns and trainee medical personnel shall be reviewed, revised and signed by medical personnel who are legally practicing in this medical institution. Further medical personnel shall write medical records after being approved by further medical institutions according to their actual qualifications for professional work.