Chinese medicine cases and cases: Chinese medicine hospitalization medical record writing format

Hospitalization Medical Record Writing and Format:

Name: Gender: Case No.

Age: Marital Status:

Occupation: Place of Birth:

Ethnicity: Nationality:

Home Address: Zip Code:

Time of Admission: Time of History Taking:

History Stated by: Reliability:

The person who stated the history: Reliability Level:

Onset of illness: Record the season of the onset of an acute illness or the onset of an acute episode of a chronic illness.

Questioning

Complaint: briefly record the main symptoms (site, nature) or signs that the patient feels the most pain, duration, and generally should not be replaced by a diagnosis or examination results. Multiple complaints should be

listed in the order of occurrence, such as palpitations for three years, swelling for one day, wheezing for four hours.

History of the present illness: inquire in detail about the development of the disease and the process of diagnosis and treatment around the main complaint, focusing on the causative factors, causes, time, form, the first symptoms, the main symptoms and accompanying symptoms (location, nature), the development of the disease and the evolution of the process of examination, diagnosis, treatment, the name of the Chinese and Western medicines used, dosage, usage and time of use of medication, as well as other special therapies, the response to treatment and the changes in symptoms, signs and symptoms, and the present situation and the results of treatment.

Past history: Record past health. Clear, chronological and systematic review of past illnesses. The history of the past, and the history of contact with infectious diseases.

Personal history: Record the place of birth, residence, living environment and conditions, life and work. The first is a record of the state of health, dietary habits, and special hobbies. The history of the patient's life and work, dietary habits and special hobbies.

Marriage and childbearing history: female patients should record the situation of menstruation, menstrual history, including the age of menarche, menstrual period/cycle, age of menopause; childbearing history, including the situation of pregnancy, fetus, childbirth, spouse and children's

health status.

Allergy history: medication, food and other allergies.

Family history: Record the health status of immediate family members and relatives closely related to the life of the person, such as the death of relatives should be recorded, the cause of death, time of death and age.

Appearance, smell, and cut

Appearance and color: Including the spirit, spirit, physical appearance, and color.

Sound and odor: including language, breathing, coughing and wheezing, vomiting, big breath, groaning, intestinal sounds and various odors.

Skin and hair: hair sparseness, color, distribution; skin temperature, humidity, elasticity, and the presence or absence of rashes, sores, phlegm, lumps, swelling and so on.

Tongue: tongue moss (moss shape, moss color, fluid), tongue texture (color, fetish spots, fetish spots), tongue body (shape, form), and veins at the base of the tongue (color, form).

Pulse: Inch-mouth pulse, cut Renying and Falling-Yang pulse if necessary, and fingerprints can be written for children under two weeks old.

Looking, smelling, and cutting of the head, face, five senses, and neck:

Looking, smelling, and cutting of the chest and abdomen:

Looking, smelling, and cutting of the lumbar and dorsal region, limbs, and claws and nails:

Looking, smelling, and cutting of the anterior and posterior binary yin and the excretory matter: