Sections | Items (21 in total) |
1. Patient information | Patient’s name, gender, date of birth, nationality, marital status, occupation, work unit, address and drug allergy history. |
2. Chief complaint | Main symptoms and duration. |
3. History of present illness | Onset time. |
Main symptoms and accompanying symptoms. | |
Negative signs for differential diagnosis. | |
Treatment situation during prior visits to other hospitals. | |
4. Medical history | Personal, past or family history related to the disease. |
5. Diagnosis | Normative diagnosis name. |
6. Treatment | Treatment suggestions. |
Drug treatment, including name, usage, dosage and time. | |
Referral or follow-up. | |
Cautions. |
*Standards taken from the Ministry of Health requirements. Retrieved from: http://www.nhc.gov.cn/yzygj/s3585u/201002/0517a82e35224ee0912a5d855a9d249f.shtml, 2017.