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1、ThewritingofclinicalrecordApatient’shealthrecordplaysmanyimportantrolesandprovidesaviewofthepatient’shealthhistory/statusThebasicrequirementofclinicalrecordsInwritingupthehistoryandthephysicalexamination,theexaminershouldobeythefollowingrules:Recordallpertinent(相关的）da
2、ta,avoidextraneous（无关的）dataUsestandardformatDescribecomprehensively,usecommonterms,avoidnonstandardabbreviations（缩写）ThebasicrequirementofclinicalrecordsWritteninanall-roundway,allitemsshouldbefilled,thehandwritingshouldbeclear,notscratchy（潦草）orbealteredBeobjective(客观）
3、,usediagram（图表）whenindicatedTypes,formatsandcontentsofclinicalrecordsClinicalrecordsduringhospitalizationTheclinicalrecordsshouldbewrittenduringhospitalizationItincludes:CaserecordFirstrecordofadmissionRecordofthecourseofdiseaseRecordofconsultationRecordfortransferrin
4、gtonewdepartmentRecordofdischargeRecordofdeathRecordofsurgeryCaserecordThecaserecordshouldbewrittensystemicallyandcompletelywithin24hbyinternFormatsandcontentsofcaserecordCaserecordNameSexAgeMaritalstatusNationProfessionNativeplaceCurrentaddressDataofadmissionDataofca
5、serecordSourceReliabilityChiefcompliantHistoryofpresentillnessPastillnessSystemicreviewPersonalhistoryMarriageReproductiveandGynecologichistoryFamilyhistoryPhysicalexaminationTemperaturePulseRespiratoryBloodPressureGeneralappearance:development,nutrition(well,moderate
6、,poor)facialexpression(acuteorchronic,sufferingexpression,anxiety,fear,calm)position,gaitmentalstatus:alert,obscure（不清楚的）,lethargy（昏睡）,comacooperativePhysicalexaminationSkinandmucous:color(reddish,paler,cyanosis,yellowish,pigmentation)swelling,moisture,elasticity,blee
7、ding,rashes,subcutaneousnodular,spiderangioma（蜘蛛痣）,ulceration,scar.Thelocation,sizeandshapeshouldberecorded.Lymphnote:systemicorlocalizedlymphnotes(submaxillary,下颚；posteriorauricular,耳后的；neck,armpit,腋窝；groin，腹股沟).Itssize,number,tenderness,hardness,mobility,fistula（漏管）
8、,scaretc.PhysicalexaminationHeadandorgansHead:itssize,shape,tenderness,mass,hairEye:eyebrow（眉毛）,eyelash（睫毛）,eyelid,（眼睑）eyeba
