Table 1

Framework for evaluating medical records derived from 2010 national standards*

SectionsItems (21 in total)
1. Patient informationPatient’s name, gender, date of birth, nationality, marital status, occupation, work unit, address and drug allergy history.
2. Chief complaintMain symptoms and duration.
3. History of present illnessOnset time.
Main symptoms and accompanying symptoms.
Negative signs for differential diagnosis.
Treatment situation during prior visits to other hospitals.
4. Medical historyPersonal, past or family history related to the disease.
5. DiagnosisNormative diagnosis name.
6. TreatmentTreatment suggestions.
Drug treatment, including name, usage, dosage and time.
Referral or follow-up.