General items: name, gender, age, marriage, place of birth, nationality, occupation, address, etc.
Second, the chief complaint
Third, the current medical history:
1 incidence
2 Main symptoms and characteristics
3 the development and evolution of the disease
4 Accompanying symptoms
5. Record negative data related to differential diagnosis.
After diagnosis and treatment.
7 General situation
Fourth, the past history.
A systematic review of verbs (abbreviation of verb)
A summary of intransitive verb system
Personal history: birthplace and residence, living habits and hobbies, occupation and working conditions, travel history.
Eight, marriage history
Nine, menstrual birth history
X. family calendar
physical examination
Laboratory and instrument inspection
Summary of medical records
Diagnosis: initial diagnosis (outpatient service), admission diagnosis (first round) and revised diagnosis.
This is the most comprehensive diagnosis. Hehe, I don't know if you just want the current medical history or the hospital medical records. Write a standardized hospital medical record for the time being. I hope I can help you.
Question 2: What are the main aspects of the writing of the current medical history of hospitalization records to write about the occurrence, development and evolution of the current medical history, as well as the treatment process and response to treatment before admission?
Question 3: If the past medical history is related to the present disease, how to write the medical record? First, write out the symptoms and signs of the patient and the results of the current diagnosis, plus the patient's past history and the symptom estimation of this consultation, so as to link the medical history with the pathological changes.