病历书写(英文).ppt

该【病历书写(英文) 】是由【胜利的喜悦】上传分享，文档一共【43】页，该文档可以免费在线阅读，需要了解更多关于【病历书写(英文) 】的内容，可以使用淘豆网的站内搜索功能，选择自己适合的文档，以下文字是截取该文章内的部分文字，如需要获得完整电子版，请下载此文档到您的设备，方便您编辑和打印。HISTORYRECORDWhatishistoryrecordTheclinicalrecorddocumentsthepatient',whatplanstheymakeonthepatient'sbehave,whatactionstheytake,,clear,,,evaluatetheimportanceandrelevanceofeachitem,andconstructaclear,concise,,age(dateofbirth),sex,race,occupation,nationality,,thedateofadmission,thetimeatwhichyoutookthehistory,(s)’,plaintshouldincludeage,plaint,:”This70-yearoldmanhashadshortbreathforaweek.”(HPI)anized,plaint(s)onitsvariouscharacteristics:①dateofonset,②plaint,③modeofonset,courseandduration,④location,⑤relationshiptoothersymptoms,bodilyfunctionandactivities,⑥exacerbationandremissions,and⑦(PH)Itshouldincludeareviewofallpastillnesses,surgicalprocedures,andinjuries,andallergyhistory(medicine,food),(ROS)Thepurposeofsystemreviewistwofold:,includingrespiratorysystem,cardiovascularsystem,digestivesystem,Urinarysystem,hemopoieticsystem,endocrinesystem,(upationalhistory)Itincludespersonalhabits(smoking,alcoholdrinking),businesslife,sexlife,occupation(exposuretocertainirritatingagents),,sexualadjustment,thenumberofchildrenandtheirPhysicalstatus,(forfemalepatients)Ageofonset,intervalbetweenperiods,duration,amountandcharacterofflow,itantsymptoms,dateoflastmenstruation,(reproductive)historyAgeanddateofpregnancy(ies)andchildbirth(s).Dateofartificialornaturalabortions,stillbirths,operativedelivery,,thepossiblefactorsofinfertility(alsoformalepatients).