Urgent request for medical record samples of outpatient department of traditional Chinese medicine (full version)

ask

The cover of the medical record should clearly fill in the patient's name, gender, age, native place, occupation and address, and the age should not be written as "Cheng". If it is a new disease, it should be written according to the format of the newly diagnosed medical record; If it is a follow-up visit to an old disease, it should be written in the format of the follow-up medical record. The medical history and physical examination requirements of the newly diagnosed patients are more comprehensive, so as to make reference for the follow-up visit. Outpatient medical records should be filled out by the attending physician at the time of the patient's visit.

format

1. Initial diagnostic format:

* family, * year * month * day.

Main complaints:

Current disease history

Past medical history, personal history, family history, etc. (A brief record of the medical history related to the disease or other meaningful medical history is required)

Physical examination: (mainly record positive signs and meaningful negative signs)

Laboratory test results

Special inspection results

tentative diagnosis

Handling and suggestions: (1)

(2)

Signature of doctor: ××××××

2. Subsequent format:

* family, * year * month * day.

Medical history: (1) After the last diagnosis and treatment.

(2) the result of the last recommended inspection

Physical examination: (mainly record the changes of positive signs and the discovery of new positive body films)

Laboratory examination and other special examination results

Preliminary diagnosis: (If the diagnosis has not changed, there is no need to write a diagnosis; If the diagnosis changes, it should be rewritten. )

Handling and suggestions: (1)

(2)

Signature of doctor: ××××××

3. See the attached page for the cover of outpatient medical records.

example

Example of initial diagnosis

Internal medicine:1March 20, 994

Paroxysmal cough for half a month.

I began to cough after catching a cold half a month ago, showing paroxysmal and fearless cold and fever, without hemoptysis and chest pain, accompanied by a small amount of white phlegm. I ate cough syrup for three days, and the effect was not good.

I have a history of chronic cough 10 years and have been diagnosed as "chronic bronchitis". I don't smoke. Deny the history of tuberculosis.

Physical examination: blood pressure

128/80mmHg, no dyspnea, no cyanosis on lips, dry rales on both lungs, no wet rales, heart rate of 90 beats/min, regular rhythm, no murmur, flat and soft abdomen, no tenderness, no touch on liver and spleen, and no edema on both lower limbs.

Blood routine: Hb 120g/L, white blood cells.

1 1.0× 109/ l, n

0.8,

10.2 .

Initial diagnosis: acute attack of chronic bronchitis.

Treatment: (1) chest radiograph

(2) Josamycin

0.2

Total internal diameter ×3

(3) Compound Glycyrrhiza syrup

10ml

Total internal diameter ×3

Signature of doctor: ××××××

Follow-up example

Internal medicine: 65438+March 25th 0994

After the above treatment, the cough was slightly relieved and no expectoration was found.

Physical examination: Generally speaking, the lungs can't hear dry and wet rales.

Chest X-ray: The texture of both lungs is thickened, there is no subjective lesion, and the heart shadow is normal.

Treatment: (1) compound licorice syrup 10Ml.

Total internal diameter ×3

(2) Josamycin

0.2

Total internal diameter ×3

Signature of doctor: ××××××