中国普通外科在线论坛--各专科病历的书写要点(四)(Chinese general surgery online forum -- the main points for writing medical records (four)).doc
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中国普通外科在线论坛--各专科病历的书写要点(四)(Chinese general surgery online forum -- the main points for writing medical records (four))
中国普通外科在线论坛--各专科病历的书写要点(四)(Chinese general surgery online forum -- the main points for writing medical records (four))
Chinese general surgery online forum -- the main points for writing medical records (four)
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Chinese general surgery online forum - learning and further study - Medical Students - the main points for writing medical records (four)
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* posting topics: writing points for medical records (four)
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Level: novice on the road
Article: 61
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Registration: 2003-3-19
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Main points for writing medical records (four)
Neurology case history
1. have a medical history
(1) the onset of symptoms, onset time, symptoms or alleviating factors, treatment and duration etc..
(2) headache: possible causes, location, nature, time, regularity, degree, concomitant symptoms, aggravating or reducing factors of headache, etc..
(3) pain: location, nature, regularity, diffusion, causes of exacerbation, results of various treatments.
(4) numbness: its nature, distribution, spread and development process.
(5) convulsions: the age of onset, whether or not threatened, convulsions, accompanied by symptoms, duration of attack, symptoms after attack, the law of attack, past treatment, and other symptoms during the intermission.
(6): the onset and location of paralysis and disability, accompanying symptoms.
(7) visual impairment: diplopia, vision loss, etc..
2. past history
There are encephalitis, meningitis, chronic bronchitis, trauma, poisoning, parasitic diseases, cardiovascular diseases, metabolic and endocrine diseases, malignant tumors and so on.
3. histories
Hobbies,
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