病历书写重点.docVIP

Case History In-Patient Case History 住院病历 Items of Case History 1. General Data, Biographical Data 一般项目 2. Chief Complaints (C. C.) 主诉 3. Present Illness (P. I.) 现病史 4. Past (Medical) History (P. H.) 既往病史 5. Personal History (Per. H.)/ Social History 个人史/社会史 6. Family History (F. H.) 家族史 7. Medications 曾用药物 8. Allergies 过敏史 9. System Review, Review of Systems 系统回顾 10. Physical Examination (P. E.) 体格检查/查体 11. Laboratory Data 实验室与其他检查/检查资料 12. Impression (Imp.) (Diagnosis) 诊断 13. Hospital Course 住院治疗情况记录 14. Discharge Instructions/ Recommendations出院医嘱 15. Discharge Medications 出院后用药