中国普通外科在线论坛--各专科病历的书写要点(四)(国外英语资料).docVIP

中国普通外科在线论坛--各专科病历的书写要点(四)(国外英语资料) Chinese general surgery online BBS - the main points of the specialty medical records (4) Join the collection Contact us BBS to help What can I do in the BBS status, BBS status welcomes you to the general surgery study in xiangya hospital of central south university. Please write about the experience, the experience and the confusion. Chinese general surgery online BBS, study and refresher, medical student world, the main points of medical records (4) You are the fourth readers this post   * post subject: the key points of the medical records (4) Gold partner Title: warmhearted people Level: the novice is on the road Article: 61 Points: 190 Registration: the 2003-3-19 The original poster The key points (4) of the medical records -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- Neuromedical history Present history (1) the duration of the initial symptoms, the onset of the disease, the severity of the symptoms, or the reduction of the symptoms, the treatment and the length of the illness. (2) headache: possible causes, sites, properties, time, regularity, degree, companion hair symptoms, headache exacerbation or mitigating factors, etc. (3) pain: location, nature, regularity, diffusion, cause of increased seizures, and the results of various treatments. (4) numbness: nature, distribution, propagation, development process. (5) the tic: early age, with or without aura, convulsions, concomitant symptoms, symptoms, duration, attack after onset seizures rule, in the past, treatment of break any other symptoms. (6) paralysis: onset of disease, location, dysfunction, and accompanying symptoms. (7) visual impairment: the presence of diplopia, loss of vision, etc. Past history There are encephalitis, meningitis, chronic bronchitis, trauma, poisoning, p