What are the main complaints and the history of current illness written in the medical record?

The chief complaint is a summary of the main reason and duration of the patient’s visit, and should reflect the three elements of symptoms, location, and time. The chief complaint should be concise and clear, and at the same time reflect the disease process. Based on the chief complaint, the system to which the disease belongs and the severity of the disease can be preliminarily estimated for targeted examination.

History of current illness: The history of current illness is the main part of the medical history. Focusing on the chief complaint, the occurrence, development and changes of the disease, as well as the diagnosis and treatment, from the onset of illness to the time of treatment are recorded in detail according to the order of symptoms. Its content mainly includes:

(1), onset time, urgency, possible causes and incentives (including some situations before the onset of illness if necessary).

(2) The time, location, nature, degree and evolution of the main symptoms (or signs).

(3). The characteristics and changes of accompanying symptoms should also be explained. Important positive and negative symptoms (or signs) with differential diagnostic significance should also be explained.

(4) For those who suffer from chronic diseases related to this disease or those who have relapsed from old diseases, we should focus on understanding the initial situation and major changes as well as recent relapses.

(5) Where and what kind of diagnosis and treatment has been done since the onset of the disease (including date of diagnosis and treatment, examination results, name of medication and its dosage, usage, surgical method, efficacy, etc.).

(6) Important injuries and illnesses in other departments that are not related to the main disease and still need to be diagnosed and treated should be described in a separate paragraph.

(7) General conditions since the onset of the disease, such as changes in spirit, appetite, food intake, sleep, defecation, physical strength and weight, etc.

Extended information

1. The cover content of the outpatient medical record must be filled in carefully item by item. The patient's name, gender, age, work unit or address, clinic number, and public (private) expenses should be filled in by the registration office. X-ray film number, electrocardiogram and other special examination number, drug allergy status, hospitalization number, etc. must be filled in by the doctor.

2. The medical records of newly diagnosed patients should contain the "five-one signatures" (chief complaint, medical history, physical examination, preliminary diagnosis, treatment opinions and physician's signature). Among them:

①Medical history should include current medical history, past history, and personal history related to the disease, marriage, menstruation, childbirth history, family history, etc.;

②Physical examination should record the main points Positive signs and negative signs with differential diagnostic significance.

③ List the names of the initially determined or most likely disease diagnoses in separate lines, and try to avoid using words such as "to be investigated" and "to be diagnosed".

④ The handling opinions should list the drugs and special treatment methods used, further examination items, daily life precautions, rest methods and duration; if necessary, record the date of outpatient appointment and follow-up requirements, etc.

3. Return-examination patients should focus on recording the diagnosis and treatment results and disease evolution since the previous visit; the physical examination can be more focused, and the last positive findings should be repeated and attention should be paid to newly discovered signs. ; Supplement necessary auxiliary inspections and special inspections. For patients who cannot be diagnosed three times, the treating physician should ask a superior physician for examination. For diseases that are different from the last time, outpatient medical records will be written as newly diagnosed patients.

4. The date of each visit should be filled in, and emergency patients should fill in the specific time.

5. When requesting consultation from other departments, the purpose, requirements and preliminary opinions of the undergraduate department should be clearly filled out in the medical record and signed by a senior physician of the hospital.

6 . The invited consulting physician (senior physician of our hospital) should fill in the examination findings, diagnosis and treatment opinions in the consultation medical record.

7. When outpatients need hospitalization for examination and treatment, the doctor must fill in the hospitalization certificate.

8. Outpatient physicians should be responsible for filling in medical record abstracts for referred patients. 9. For notifiable infectious diseases, the epidemic reporting status should be indicated.

Baidu Encyclopedia-Medical Records

Baidu Encyclopedia-Chief Complaint