中央电大护理专业本科通科实习出科考核病历.docxVIP

附件1：中央电大护理专业本科通科实习出科考核病历科别       病室      住院号             入院时间     年     月     日   时一．一般资料姓名                 性别 □男□女     年龄     岁  民族          籍贯        婚姻                     职业                             文化程度               医疗费用支付方式 □公费  □自费  □大病统筹  □医保   □其他                   资料来源 □病人□家属 □其他              入院方式 □步行□扶行□轮椅□平车入院诊断                                                                            确定诊断                                                                      入院原因（主诉＋现病史）                                                                                                                                                                                                                                                                                                                                                                                                            既往史 □无□有□糖尿病 年□高血压 年□冠心病 年□脑血管病 年□其他      家族史 □无□有                                                                   过敏史 □无□有药物               食物               其他                      嗜 好 □无□有吸烟史    年    支/天，饮酒史    年    两/天，其他             生育月经史 月经史                            ，孕产史                             二．日常生活与心理社会资料（手术患者比较术前、术后）1．饮食情况 平时近2天食欲  食量  体重  嗜好  其他  2．饮水情况 平时近2天量  种类  其他         3．大便情况 平时近2天次数  性状  颜色  其他     4．小便情况 平时近2天次数  量  颜色  尿管  其他   5．睡眠情况 平时近2天时间  质量  药物  其他     6．自理情况 平时近2天独立  协助  依赖  其他     7．目前自我感觉                                                                      8．精神情绪   □稳定□焦虑□紧张 □恐惧□其他                                   9．对疾病认识 □不了解     □部分了解    □完全了解（□希望了解   □不希望了解）三．与护理诊断相关的辅助检查结果□血常规                                                                            □血生化                                                                            □ECG                                                                               □x－ray                                                                            □其他