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病历是医生诊治病人疾患的记录,就是中医的医案。主要内容是:记录病人以往的健康情况,发病经过,现在症状,诊断结果,治疗措施,医疗效果等。举凡有关病人的身份各项,如姓名、性别、年龄、籍贯、婚姻状况、职业、住址、就诊日期、时间、住院号码等等,都应详细记录,更要求字体端正,辞句简洁,确切,通畅易懂,备作可靠的参考资料。同时也是医生结合日常工作练习写作的一项工作。
Medical record is a record of doctor’s diagnosis and treatment of patient’s illness, that is, medical record of Chinese medicine. The main content is: record the patient’s previous health, after the onset, the symptoms, diagnosis, treatment, medical effects and so on. All the relevant status of the patient, such as name, sex, age, place of origin, marital status, occupation, address, date of visit, time, hospital number and so on, should be detailed records, but also requires correct fonts, concise, precise, Unobtrusive, ready for reliable reference. It is also a job for doctors to practice writing in combination with their daily work.