中国普通外科在线论坛--各专科病历的书写要点(二)（Chinese general surgery online forum -- the main points for writing medical records (two)）.docVIP

中国普通外科在线论坛--各专科病历的书写要点(二)（Chinese general surgery online forum -- the main points for writing medical records (two)） Chinese general surgery online forum -- the main points for writing medical records (two) Join the collection Contact us Forum Help Login registration, search, chat rooms, self style forums, status forums, galleries, what can I do? Welcome to the general surgery department of Xiangya No.2 Hospital, Central South University. Please write down your experience, information, pleasure, questions and puzzles here. Chinese general surgery online forum - learning and further study - Medical Students - the main points for writing medical records (two) You are the tenth person reading this post AP * posting topics: writing points for medical records (two) Gold partner Title: enthusiastic person Level: novice on the road Article: 61 Points: 190 Registration: 2003-3-19 The landlord Main points for writing medical records (two) Basic surgical history 1. have a medical history (1) surgical infection: date of onset, site of infection, causes and predisposing factors (no trauma, overwork, chronic malnutrition, diabetes, uremia, advanced cancer, abuse of antibiotics or glucocorticoid, chemotherapy and radiotherapy have no history), pain and swelling of dysfunction of local symptoms, there is no chills fever Fatigue, headache, loss of appetite and other symptoms of the body. (2) injury: the time of injury, location, injury causes, nature, violence injured size, posture, focus and direction, injury type and nature; no body is extruded, there is no pain, swelling, bleeding and dysfunction (nature and quantity) there is no such local symptoms, disturbance of consciousness, breathing difficulties and abnormal urination and other symptoms; and after treatment effect after injury. (3) thyroid disease: masses found date, size change, there is no pain and hoarseness, shortness of breath, dysphagia and compression symptoms, there is no fever, palpitation, sweating, excitement,