新建 M病历书写档(国外英文资料).doc

新建 M病历书写档(国外英文资料) 2004-5-13 7:26:00? 5305 Admission form of medical records anonymous ??????????????? ? To be admitted to the medical records (upper case). The name Some dont gender Career (job) age address marriage Date of admission ? Nationality (province, city, county) Record the date national History of the narrator Chief complaint (main symptom and duration) The history of the present medical history (from the onset of the onset of the illness to the main symptoms of this visit) Past history (general health, previous illness, vaccination, drug allergy) System review The history of infectious diseases. The respiratory system. The circulatory system is going to be x times x times x times x. The digestive system. The genitourinary system is x * * * * *. The hematopoietic system. A disease of endocrine and metabolic disorders. Motor system disease (muscle, bone, joint). The nervous system. The nervous system. The history of trauma and surgery. Personal history (including the place of birth, place of residence and tourist destination, living and eating habits, past and present occupations, menstrual history, history of marriage and production) x x x x x x x x x. Family history (inquiring about the health status of the parents, brothers, sisters and children of the patient, illness and death. ......... Physical examination (one line) The pulse of the temperature? Blood pressure The general development (normal, bad condition), nutrition (good, moderate and bad), consciousness, such as clear, fuzzy, lethargy, coma, delirium), position (to be automatic, passive, force), face and expression (quiet, be agitated, pain, anxiety, acute or chronic ill, special features). Skin, mucous membrane (normal color, pale, flush, purple purple, yellow dye, pigmentation, or lack thereof), elasticity, temperature and humidity (if necessary), skin rash, spider nevi, subcutaneous bleeding, edema, ulcers, scar, subcutaneous nodules or masses. The area, size, number, hardness, tenderness, m