规范骨科病历（Standard Department of orthopedics case history）.docVIP

规范骨科病历（Standard Department of orthopedics case history） Department of orthopedics (orthopedics) medical record writing requirements Department of orthopedics, also known as orthopedic surgery, its basic content and general surgical records of the same, but must pay special attention to the following: (a) medical history 1. the onset of onset time, priorities, what causes and conditions after. 2. injury history, injury time, cause, place and detailed process, with special attention to injury, posture, position, body, ground, or direction of violence, whether or not there is any wound. In case of traffic accidents, we should know what kind of vehicles and their load, speed and after treatment. The wound should understand the circumstances and injuries caused by weapons. 3. symptoms such as pain (including causes, location, extent, duration, and influencing factors), lameness, swelling, deformity, joint stiffness (or contracture), weakness and dysfunction, systemic manifestations, etc.. 4. past history should include history of trauma, history of tuberculosis and other infectious diseases, as well as the history of long-term treatment with medications (especially hormone drugs), drug reactions, allergies, bleeding tendency, etc.. 5. histories, such as occupation, experience, labor, work, etc.. 6., family history, the family history of tuberculosis, tuberculosis, hemophilia, gout, congenital malformations and genetic abnormalities and other medical history. (two) physical examination Specialist examinations should pay attention to the following: 1. look at the patients limb posture, gait, whether or not limp, whether or not crutches, etc.. The affected part without subcutaneous venous engorgement, swelling and ecchymosis, scar, hyperpigmentation, sinus, exudates and its properties. Head, neck, trunk and limbs is symmetrical, no change in spinal physiological curvature, Does the limb rotate, become angular, each joint has flexion, adduction, abduction, varus, valgus and