Instruction
1
Specify on the cover sheet surname, name, patronymic of patient, date of birth, home address, place of employment, date of admission to medical institution and admission diagnosis. Write clearly when filling in the history of the disease from the hands.
2
In the section "passport part" enter the surname, name, patronymic of patient, age, date of admission and admission diagnosis. In the treatment process, complete this section clinical and final diagnoses, and discharge date. When writing a diagnosis, highlight the main and concomitant diseases, their complications.
3
List all the patient's complaints in the section "Application for admission", detail them. If the patient is taciturn, alone ask questions.
4
In the "disease History" describe where the patient first felt ill, as of this moment, before getting to the hospital changed his condition.
5
In "the History of life describe how the patient grew and developed in childhood, which the disease and operations have moved if he had allergies. If the patient has bad habits, this do record in this section history of the disease.
6
The sheet "Objective examination" complete data examination of the patient. Describe all the changes that are found.
7
Put a diagnosis on the basis of complaints, anamnesis and data of objective inspection in the section "Preliminary diagnosis".
8
Assign treatment, and record it in the "list of appointments". Drug names write in a column on the left side of the page on the Latin language in the form of recipes. Research, which must pass the patient record to the right of the recipes.
9
Every day in "Diary of observation" describe the patient's complaints during the inspection, what has changed in his condition
10
Before discharge write a discharge summary, which briefly list the data of all sections and the result of treatment.
