How to write the inpatient medical records of traditional Chinese medicine

Hospital TCM outpatient medical records

March 20, 1965 438+02

Name: Li Yang

Gender: Female

Age: 18

Occupation: None

Chief complaint: Cough for 3 days.

History: The patient was caught in the rain 3 days ago, accompanied by cough, aversion to cold, headache, pale mouth, unpleasant stool and irregular urination.

Past history: None

Allergy history: cephalosporin allergy.

Others:

Tongue image: red tongue, white and greasy fur.

Pulse condition: the pulse is tight.

Diagnosis:

Traditional Chinese medicine diagnosis: cough (wind-cold with dampness)

Western medicine diagnosis: upper respiratory tract infection

Handling:

(1) TCM treatment: expelling wind and cold, resolving phlegm and relieving cough.

(2) Prescription: Su Xing Powder.

(3) medicine: perilla leaf 10g

Almond 10g

Fangfeng 10g

Platycodon grandiflorum 10g

Pogostemon cablin 10g

Magnolia officinalis 10g

Licorice 10g

(4) Precautions: 3 bowls of water are decocted with strong fire 15 minutes, and taken with warm clothes for 3 times.