Key points of medical record writing in each major.

It is the same as the medical records of western medicine, plus the onset of solar terms.

2. Chief complaint

Describe the main pain (symptoms) and occurrence time of the patient's consciousness.

3. Current medical history

The time, season, place, etiology and evolution, the nature and degree of main symptoms and related syndromes, the treatment process and effect response of rash were described in detail.

4. Past medical history

Briefly describe the main diseases, time and treatment in the past, and reflect some information related to this disease.

5. Other history

Including personal history and family history. Women should record their menstrual history and delivery history, and children should record their feeding history and growth and development history.

6. Four diagnostic tests

Prioritize and highlight key points, and describe the objective data obtained by four clinics. The main contents are as follows:

(1) See a doctor: look, posture, tongue (quality, fur color, dampness, shape), other abnormal phenomena (such as mouth, ears, nose, eyes, fingernails, macula, whiteness, etc. ), the color, nature and quantity of relevant secretions and excretions, and the fingerprints of pediatrics.

(2) Hearing and diagnosis: sound (voice, breath and related abnormalities, such as cough, phlegm, vomiting, etc. ) and smell (including the smell of secretions and excretions).

(3) Consultation: the main symptoms and other complications now.

(4) Pulse-taking: pulse-taking (three parts and nine phases), pressing the abdomen and related head and neck, chest, limbs, spine and joints.

7. Dialectical analysis

(1) Distinguish the etiology, pathogenesis and location of the disease.

(2) Analyze and determine the name and syndrome type of TCM diseases, and put forward the basis of syndrome differentiation.

(3) To estimate the development and prognosis of the disease.

8. Physical examination summary

T, p, r, BP, plus sign and related minus sign.

9. Physical and chemical inspection

List the examination results and time that are meaningful for diagnosis and differential diagnosis.

10. First visit

Write it on the lower right. Traditional Chinese medicine first followed by western medicine, double diagnosis (corresponding to western medicine diagnosis is no exception). Traditional Chinese medicine: name of disease, syndrome type and stage. Patients with concurrent diseases can fill in more than one diagnosis [for example: ① pulmonary tuberculosis (yin deficiency type); ② Pulmonary abscess (suppurative stage)]. Western medicine: fill in the order of main diseases and accompanying diseases [for example: ① tuberculosis; ② Lung abscess].

1 1. Signature

Must be responsible for grade review, sign the full name at the bottom right.