What is the standard mode of medical records?

Model essay on medical record writing of traditional Chinese medicine (integrated traditional Chinese and western medicine) Name: gender: male age: 5 years old Nationality: birthplace: marital status: unmarried occupation: unit: postal code: permanent address: admission time: April 2002 13 10, and medical history collection time: April 2002/kloc-0. 5-day cough history: the baby started to have fever, cough, expectoration, nasal congestion and vomiting stomach contents 5 days ago, with no obvious inducement. I visited the outpatient department of our hospital many times, and I was treated with traditional Chinese medicine, Xianfeng No.6 and Houttuynia Cordata by intravenous drip, but my symptoms did not improve. I came to our outpatient clinic again today. For further systematic treatment, I was admitted to the hospital from the outpatient department. Symptoms at admission: mental fatigue, fever, cough, expectoration, shortness of breath, vomiting of stomach contents once, earache, no tinnitus, anorexia, poor sleep, bad stool, three times a day, and urination. Past medical history: healthy in the past, denying the history of chickenpox, measles, tuberculosis and hepatitis. Personal medical history: My mother was healthy during pregnancy, gave birth to her first child at full term, and her weight and height at birth were unknown. No history of asphyxia and hypoxia at birth, no pathological jaundice, mixed feeding, regular addition of complementary food, normal growth and development, normal intelligence, timely vaccination. Allergy history: private prosecution of Qingkailing allergy history, denial of other food and drug allergy history. Menstrual marriage and childbearing history: family history: parents' health. Deny the family history of hereditary diseases. Physical examination T37℃P92 times/min R20 times/min bp Overall condition: looking at God: conscious, tired, with normal expression. Look at the color: normal face, white color.

legal ground

Basic norms of medical record writing

Thirteenth outpatient (emergency) medical records are divided into initial medical records and follow-up medical records.