Who has a TCM medical record template, a TCM medical record template

There is a book on TCM diagnostics.

Outpatient Medical Records:

Date of chief complaint plus symptom signs.

Dialectic, rule.

Recipe. Signature.

Now it is generally omitted dialectic, rule of rule. Because of conservatism.

Name: Zhang Gender: Female.

Age: 36 years oldNationality: Han nationality.

Marital Status: Married Occupation: Worker.

Description: Frequent urination, urgency, and pain for 2 weeks, aggravated for 2 days, accompanied by low back pain and fever.

History of present illness: 2 weeks ago, due to unclean vagina, frequent urination and urgency, painful urination, at that time after rest and self-administration of haloperic acid. 2 days ago, due to the aggravation of symptoms after exertion, short and astringent urination, dripping and stinging, low back pain, fever, chills, bitter mouth, burning sensation during urination, dark yellow and turbid urine, so I came to the clinic.

Present symptoms: frequent urination, dripping and stinging, low back pain, fever, chills, bitter mouth, burning sensation during urination, dark yellow and turbid urine. Clinical Laboratories.

Anamnesis: leucorrhoea, sometimes with a history of vaginal itching for 2 years. No other significant medical history is available.

Personal History: There are no special circumstances to cover.

Menstrual and marital history: Menstrual history: 15. Married. Gave birth to 1 son, 10 years old. 1 miscarriage.

Family history: Parents who are alive and deny a history of familial hereditary disorders.

Physical examination: t::18 p:96 b:120 75mmHg

Overall condition: clear consciousness, good spirits, feverish appearance, normal posture, clear speech, no abnormal odor smell, red tongue, yellow greasy, pulse slippery.

**Mucosa and lymph nodes: ** and mucosa without yellow staining, no macules and scrofula, superficial lymph nodes are not palpable and enlarged.

Head, face and neck: shiny hair, no abnormalities in the eyes, ears, nose and mouth. There is no rigidity in the neck, the trachea is centered, and there is no gall. Clinical Laboratories.

Chest: symmetrical ribcage, no deformity; Breath sounds in both lungs are clear, and no wet and dry rales are heard; The apical beat and dullness of the heart were normal, the heart rate was 96 beats, the rhythm was uniform, and no murmur was heard.

Abdomen and back: the abdomen is flat and difficult, there is tenderness at the upper ureteral point in the abdomen, no rebound tenderness, and no palpable mass; The liver and spleen are not reached, and the gallbladder is not tender (negative Murphy's sign). There is percussion pain in both kidneys.

Spine and limbs: no deformity, rigidity, percussion pain in the spine, and no restriction of movement; The limbs are normal and not swollen.

Anterior and posterior yin and excretion: the anterior and posterior yin are not detected (or no abnormalities are found), and the urine is dark yellow and turbid (or the excrement is not carved out).

Nervous system: no abnormalities found.

Laboratory tests: urinalysis showed a small amount of protein, leukocytes +++ hp, red blood cells ++ hp, leukocyte casts + LP. Complete blood count shows white blood cells.

109 l, neutrophil 84% of the hall cell. Cleaning interrupted urine bacterial culture showed E. coli, colonies 105 ml.

Basis for disease differentiation and syndrome differentiation: it is known that the lower yin is unclean, and the evil of turbidity invades the bladder, resulting in dampness and heat, the bladder is vaporized, and the waterway is unfavorable, so it is a gonorrhea syndrome, so the clinical syndrome can be seen as frequent urination, urgency, dysuria and other gonorrhea syndrome witnesses. Dampness and heat accumulate and burn, and the bladder is vaporized and lost, so the urine is short, burning and stinging, and the drowning color is dark yellow and turbid; The waist is the home of the kidneys, and the evil of dampness and heat invades the kidneys, so it is seen that the low back pain and the kidney area percussion pain; Dampness and heat are contained, and evil and good are contending, so we see fever, chills, and bitter mouth; The tongue is red, the moss is yellow and greasy, and the pulse is slippery, all of which are signs of dampness and heat.

Case analysis? Patient name, sex, age.

Complaints (which can be added to the history of the disease) plus signs of tongue and pulse.

Diagnosis: TCM diagnosis, syndrome type.

Treatment: Prescription:

Analyze the prescription. For example:

Patient Zhang XX, female, 32 years old.

The patient went out 3 days ago and got cold, and when he woke up this morning, he felt dizzy, fatigue, slightly chilly, cough, white sputum, no sweating, fever, etc., the tip of the tongue was red, the moss was thin and white, and the pulse floated.

Diagnosis: external sensation (wind chill cold).

Rule: Relieve the surface and dissipate the cold, and sweat at the warm temperature.

Prescription: Ephedra decoction.

Analysis: Analysis based on the chief complaint and the composition of the prescription is sufficient.

I don't understand hi me.

Generally, I write a set of yin and yang, qi and blood, a set of looking, hearing and asking questions, and some traditional Chinese medicine theories, and finally conditioning.

Summary. Hello, dear, your question has been inquired for you, after the end of the hospital, take your ID card discharge certificate number, and go to the hospital record room to print. Problem Description:

Nowadays, many cities do not have paper medical insurance books. After the general resident receives a medical insurance card, he or she cannot see the writing of his medical record. A doctor prescribes medication that requires a diagnosis of the disease, and one symptom corresponds to multiple diagnoses.

Sometimes, some doctors make a more casual diagnosis. This also means that if you don't take medical records, current medical history and diagnosis, you don't know, you won't remember, and you may be surprised. I don't know how well my medical history is written and diagnosed.

In the future, when buying insurance, there are many hidden dangers. The most common situation is that when you buy insurance, but when you make a claim (especially medical insurance, which is found to be a pre-existing condition in the medical records), there will be a dispute over the refusal of the claim and the invalidity of the policy. Then it is recommended that you print out your electronic medical record after each visit.

It is convenient to make health notices when applying for insurance to eliminate hidden dangers of claims.

Hello, dear, your question has been inquired for you, after the end of the hospital, take your ID card discharge certificate number, and go to the hospital record room to print. Problem description: Nowadays, many cities do not have paper medical insurance books.

After the general resident receives a medical insurance card, he or she cannot see the writing of his medical record. A doctor prescribes medication that requires a diagnosis of the disease, and one symptom corresponds to multiple diagnoses. Sometimes, some doctors make a more casual diagnosis.

This also means that if you don't make medical records, current medical history and diagnosis, you don't know it, and you won't remember it, and you may call your side people out of your own surprise. I don't know how well my medical history is written and diagnosed. In the future, when buying insurance, there are many hidden dangers.

The most common situation is that when you buy insurance, but when you make a claim (especially medical insurance, which is found to be a pre-existing condition in the medical records), there will be a dispute over the refusal of the claim and the invalidity of the policy. It is recommended that you print out your electronic medical record after each visit. It is convenient to make health notices when applying for insurance to eliminate hidden dangers of claims.

Outpatient Medical Records:

Requirements] The cover of the medical record should clearly fill in the patient's name, gender, age, place of origin, occupation, address, etc., and the age cannot be written "Cheng". If it is a new disease, it should be written in the format of the initial medical record; If it is a re-examination of an old disease, it should be written in the format of the re-examination medical record. The medical history and physical examination of the newly diagnosed patients should be more comprehensive for reference at the follow-up visit.

Outpatient medical records should be completed by the attending physician at the time of the patient's visit.

Format] 1Initial Consultation Format:

Branch, year, month, day.

Chief complaint: history of present illness.

Anamnesis, personal history, family history, etc. (a brief record of the medical history related to the onset of the disease or other meaningful medical history is required).

Physical examination: (mainly recording positive signs and meaningful negative signs).

Laboratory findings.

Special test results.

Initial diagnosis. Handling and Suggestions: (1).

2) Physician's signature:

2.Follow-up Format:

Branch, year, month, day.

Medical history: (1) The condition after the last diagnosis and treatment.

2) The results of the last recommended inspection.

Physical examination: (mainly to record changes in positive signs and new positive body findings).

Laboratory tests and other special test findings.

Initial diagnosis: (If the diagnosis has not changed, it is not necessary to write the diagnosis again, and if the diagnosis has changed, the diagnosis should be written again.) ）

Handling and Suggestions: (1).

2) Physician's signature:

3 See the attached page for the cover of the outpatient medical record.

Example] Example of initial diagnosis.

Internal Medicine: March 20, 1994.

Paroxysmal cough for half a month.

Half a month ago, he began to cough after receiving a cold, paroxysmal, fearless of cold and fever, no hemoptysis and chest pain, accompanied by a small amount of white viscous sputum. I have taken cough syrup for 3 days, but the effect is not good.

He has a history of chronic cough for more than 10 years, has been diagnosed with "chronic bronchitis", and is not a smoker. Denial of a history of tuberculosis.

Physical examination: BP 128 80mmHg, no dyspnea, no cyanosis of the lips, scattered dry rales in both lungs, no crackles in crackles, heart rate 90 min, rhythm, no murmur, flat abdomen without tenderness, liver and spleen without palpation, and no edema in both lower limbs.

Complete blood count: HB120G L, WBC, N,

Initial diagnosis: acute exacerbation of chronic bronchitis.

Processing: (1) Chest x-ray.

2) Tropethamycin.

3) Compound licorice syrup 10ml

Physician's signature:

Example of a follow-up visit. Internal Medicine: March 25, 1994.

After the above treatment, the cough was slightly relieved, and the phlegm was no longer coughing.

Physical examination: generally good, no dry, crackles are heard in both lungs.

Chest x-ray: thickened markings in both lungs, no major lesions, normal cardiac shadows.

Processing: (1) 10ml of compound licorice syrup

2) Tropethamycin.

Physician's signature: