中国普通外科在线论坛--各专科病历的书写要点(四)（Chinese general surgery online forum -- the main points for writing medical records (four)）.doc

中国普通外科在线论坛--各专科病历的书写要点(四)（Chinese general surgery online forum -- the main points for writing medical records (four)） Chinese general surgery online forum -- the main points for writing medical records (four) 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 (four) You are the fourth person reading this post AP * posting topics: writing points for medical records (four) 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 (four) Neurology case history 1. have a medical history (1) the onset of symptoms, onset time, symptoms or alleviating factors, treatment and duration etc.. (2) headache: possible causes, location, nature, time, regularity, degree, concomitant symptoms, aggravating or reducing factors of headache, etc.. (3) pain: location, nature, regularity, diffusion, causes of exacerbation, results of various treatments. (4) numbness: its nature, distribution, spread and development process. (5) convulsions: the age of onset, whether or not threatened, convulsions, accompanied by symptoms, duration of attack, symptoms after attack, the law of attack, past treatment, and other symptoms during the intermission. (6): the onset and location of paralysis and disability, accompanying symptoms. (7) visual impairment: diplopia, vision loss, etc.. 2. past history There are encephalitis, meningitis, chronic bronchitis, trauma, poisoning, parasitic diseases, cardiovascular diseases, metabolic and endocrine diseases, malignant tumors and so on. 3. histories Hobbies,