住院病历模板（Inpatient medical record template）.docVIP

住院病历模板（Inpatient medical record template） Admission Note Name: place of birth: sex: Nationality: age: Date of admission: Marriage: record date: occupation: Medical history statement: Unit or address: Reliability: Chief complaint: the main symptom (or sign) and the duration of a patients visit. History of Present Illness： Past history: deny the history of hypertension, coronary heart disease, deny the history of hepatitis and tuberculosis, and the history of close contact, no history of operation, history of trauma and the history of transfusion of blood products, no history of allergy, and preventive vaccination according to plan. System review: Respiratory system: no cough, hemoptysis, chest pain, fever, night sweats and history. Circulatory system: no palpitation, shortness of breath, cyanosis, precordial pain, lower extremity edema and hypertension. Digestive system: no loss of appetite, belching, dysphagia, vomiting, abdominal pain, abdominal distension, diarrhea and black history. Genitourinary system: no urgency, frequent urination, dysuria, hematuria, nocturia and facial edema history. The blood system: no pallor, fatigue, subcutaneous congestion and hemorrhage, epistaxis, gingival bleeding history. Endocrine and metabolism: no abnormalities, sexual dysfunction, secondary sexual characteristics change and personality changes, there is no amenorrhea, lactation, obesity has no change; nutrition disorders, excessive drinking and eating disorders, in view of history; there is no abnormal skin pigmentation, hair distribution etc.. Muscles and joints: no red, swelling, heat, pain, and movement disorders. The nervous system: no headache, dizziness, dizziness, insomnia, convulsions, mental disorders, limb spasm and paralysis. Personal history: a long history, No history of water contact of schistosomiasis, There is no endemic disease or epidemic disease area, residence history, no poison, dust and radioactive material contact history, regular life, lack of physical a