中医门诊病历书写规范.doc

中医门诊病历书写规范姓名:性别：年龄： 科别：年月日 （一般信息按门诊通用病历要求填写）主诉：病人最痛苦的主要症状（或体征)及持续时间.病史:主症发生的时间、病情发展变化的情况，诊治经过.既往史:必要的、特殊的既往史、药物食物过敏史等。体格检查：(包括望、闻、切诊内容） 与诊断有关的望、闻、切诊的阳性所见，必要的体格检查等。 舌象（舌体、舌质、舌苔、舌底脉络). 脉象(两周岁以下小儿需察食指络脉)。实验室检查及特殊检查结果.辨证分析：归纳四诊所得的主症、阳性体征、舌象、脉象等，扼要分析病位、病因、证候属性、病机转化。诊断：含中医病（症）名，证名及西医病名诊断。可写疑似诊断，但门诊三次，仍未确诊者，应请上级医师会诊，协助诊断.治法：根据辨证写出指导用药的理法.中医治疗:1、方：运用成方可写方名及加减，自拟方可写自拟方名或标示“自拟方字样。药:每行写四味药,药物名称右上角写特殊煎、服法,右下角写剂量“g”可写“克”。药方下面写剂数、用法、用量频次、特殊注意事项等。2、中成药3、非药物疗法医嘱：进一步诊治建议、护理、饮食宜忌、不适随诊、复诊建议等。 医师签名(盖章):初诊记录中医门诊复诊病历规范复诊日期：主观症状的变化情况描述：客观体征的变化情况记录：包含望、闻、切诊内容。检查结果:必要的检查结果，没有可不填辩证分析：对病情变化的简要病机分析:诊断或更正诊断：含中医病（症）名，证名及西医病名诊断。治法：根据辨证写出指导用药的理法.中医治疗：1、方：运用成方可写方名及加减,自拟方可写自拟方名或标示“自拟方”字样。药：每行写四味药，药物名称右上角写特殊煎、服法，右下角写剂量“g”可写“克”.药方下面写剂数、用法、用量频次、特殊注意事项等。2、中成药3、非药物疗法医嘱：医师签名（盖章）：复诊记录范例姓名:刘性别:女年龄：29岁科别：内科时间：1994年2月5日(初诊) 主诉:尿频、尿急、尿痛伴腰痛4天。病史：患者诉4天前外出旅游回来,即出现尿频、尿急、尿痛，伴少腹胀、腰痛，公司医务室给予氟呱酸0.2克，每日三次,效果不佳，遂来我院门诊就诊，现症见尿频、尿急、尿痛，腰酸痛，少腹胀，下肢乏力，口干多饮，纳差，大便稀。无畏寒、发热等症。望、闻、切诊:神志清楚，精神不振,面色红。语言清晰，呼吸均匀.舌体大小适中，活动灵活，舌质红，舌苔薄黄而腻，舌底脉络未见迂曲，脉滑数.既往史：既往体健，否认药物食物过敏史。体格检查:T36。5C,BP16/10kPa，心肺未见异常。双肾区有叩击痛及压痛,双下肢无水肿。实验室检查：血常规：Hb113g/LWBC10.5109/LN0。80L0。20尿常规：GLU+PRO+WBC 05个/HPRBC 04个/HP辨证分析：患者系外出旅游后,出现尿频、尿急、尿痛伴腰痛4天，双肾区有叩击痛及压痛,双下肢无水肿,舌质红，舌苔薄黄而腻,脉滑数.归纳四诊所得，本病当属湿热下注之淋证。病位在肾及膀胱，病性属实。总因湿热邪毒侵入膀胱，蕴结下焦,致膀胱气化不利，乃成此证。诊断：中医诊断:淋证（湿热下注) 西医诊断:急性肾盂肾炎治法:清热利湿通淋方：八正散加减：药：木通10g 车前仁20g(包煎）扁蓄10g滑石20g(包煎）栀子10g 瞿麦10g 茯苓10g 黄柏10g凤尾草30g 甘草5g4剂， 头煎加水400ml，水煎20分钟，取汁200ml，二煎加水300ml，取汁150ml，两煎混合，日一剂，分二次口服。医嘱:1.避风寒，慎起居，饮食宜清淡。2。按时服药,忌房事。3.四天后复诊。4。不适随诊。世界观人人都有，而哲学只有经过系统的学习的人才能掌握它。世界观是自发成的，是不系统的、不自觉的、缺乏严密的逻辑和理论论证，而哲学则是把自发的、零散的、朴素的世界观加以理论化和系统化，因而具有严密的逻辑和完整的理论体系。appearance of the weld appearance quality technical requirements of the project must not have a molten metal stream does not melt the base metal to weld, weld seam and heat-affected zone surface must not have cracks, pores, defects such as crater and ash, surface smoothing, weld and base metal should be evenly smooth transition. Width 2-3 mm from the edge of weld Groove. Surface reinforcement should be less than or equal to 1 + 0.2 times the slope edge width, and should not be greater than 4 mm. Depth of undercut should be less than or equal to 0.5 mm, total length of the welds on both sides undercut not exceed 10% of the weld length, and long continuous should not be greater than 100 mm. Wrong side should be less than or at 0.2T, and should not be greater than 2 mm (wall thickness mm t) incomplete or not allow 7.5 7.5.1 installation quality process standards of the electrical enclosure Cabinet surface is clean, neat, no significant phenomenon of convex, close to nature, close the door. 7.5.2 Cabinet Cabinet face paints no paint, returned to rusted, consistent color. 7.5.3 uniform indirect gap from top to bottom, slot width 1.5mm 7.5.4 adjacent Cabinet surface roughness is 0. 7.5.5 the cabinets firmly fixed, crafts beautiful. 7.5.6 Cabinet surface gauge, switch cabinet mark clear, neat, firm paste. 7.5.7 Terminal row of neat, is reliable, the appearance is clean and not damaged. 7.5.8 cables neat and clean, solid binding, binding process in appearance. 7.5.9 the first cable production firm, crafts beautiful, clear signage does not fade. 7.5.10 fireproof plugging tight, no cracks and pores. 7.6 7.6.1 of the standard electrical wiring quality technology cable a, the multi-core wire bunch arrangement should be parallel to each other, horizontal wire harness or wire should be perpendicular to the longitudinal multi-core wire bunch. The distance between the wire harness and wire harness symmetry, and as close as possible. B-core wiring harness into round, multi-core wire bunch used g wire binding, fastening