You need to help write a medical record, and the doctor will write the medical record by hand to hel

The medical record must be signed by the doctor. "Basic Standards for Writing Medical Records" Article 8: Medical records shall be written in accordance with the provisions and signed by the corresponding medical personnel.

Medical records written by intern medical personnel and probationary medical personnel shall be reviewed, revised, and signed by medical personnel registered with the medical establishment.

Medical personnel who are studying for further education shall write medical records after being determined by medical institutions according to the actual situation of their professional work. Article 13: Outpatient (emergency) medical records are divided into initial medical records, wide records, and follow-up medical records.

The written content of the initial medical record shall include the time of consultation, department, chief complaint, present medical history, past medical history, positive signs, necessary negative signs and auxiliary examination results, diagnosis and ** opinions and physician signatures.

The written content of the follow-up medical record shall include the time of consultation, department, chief complaint, medical history, necessary physical examination and auxiliary examination results, diagnosis, ** handling opinions, and the physician's signature.

The time of the emergency medical record should be specific to the minute.

Legal basis. Article 8 of the Basic Standards for Writing Medical Records Medical records shall be written in accordance with the provisions and signed by the corresponding medical personnel of Huaibi.

Medical records written by intern medical personnel and probationary medical personnel shall be reviewed, revised, and signed by medical personnel registered with the medical establishment.

Medical personnel who are studying for further education shall write medical records after being determined by medical institutions according to the actual situation of their professional work. Article 13 Outpatient (emergency) medical records are divided into initial diagnosis and careful history records and follow-up medical records.

The written content of the initial medical record shall include the time of consultation, department, chief complaint, present medical history, past medical history, positive signs, necessary negative signs and auxiliary examination results, diagnosis and ** opinions and physician signatures.

The written content of the follow-up medical record shall include the time of consultation, department, chief complaint, medical history, necessary physical examination and auxiliary examination results, diagnosis, ** handling opinions, and the physician's signature.

The time of the emergency medical record should be specific to the minute.

1. The medical record must be signed by the attending staff, and when the party wants to enjoy the medical insurance treatment, it should also be reviewed and signed by the staff of the medical insurance department; 2. When going through the reimbursement procedures: if the insured person receives medical treatment in another place, he or she should bring the discharge summary, hospitalization certificate, receipt and details, social security card, referral certificate, and valid ID card issued by the remote medical institution to the local social security department for reimbursement; 3. Otherwise, the above documents and materials (except for the referral certificate) should be presented to settle directly when going through the discharge procedures and paying the fee. According to the Social Insurance Law of the People's Republic of China:

Article 29 The part of the medical expenses that should be paid by the basic medical insurance shall be directly settled by the social insurance agency and the medical institution and the drug business unit. The administrative department of social insurance and the administrative department of health shall establish a system for the settlement of medical expenses for medical treatment in other places to facilitate the insured persons to enjoy basic medical insurance benefits.

Legal basis. Article 29 of the full text of the Social Insurance Law of the People's Republic of China The part of the medical expenses of the insured persons that should be paid by the basic medical insurance** shall be directly settled by the social insurance agency and the medical institution and the drug business unit. The social insurance administrative department and the health administrative department shall establish a settlement system for medical expenses for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance benefits by insured persons.

Lying about your illness or negotiating with your doctor to write down the severity of your condition.

Summary. But you need to send ** to take a look. A lot is really not easy to tell.

But you need to send ** to take a look. A lot is really not easy to tell.

Well, it's just a record of your symptoms.

If you have any symptoms, he will record them for you.

It's nothing more than blood pressure, feeling mental state, and so on.

It should be anemia.

I'm checking it out**.

I need to know what he diagnosed for me.

Atopic dermatitis.

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: