1. Overview
Including the child's name (birth name), gender, age, nationality, hospitalization date, parents' name, age, occupation, education level, home address, telephone number, etc. Accurately record the age of the child and indicate the date of birth if necessary.
2. Chief complaint
The main reasons and duration of children coming to the hospital.
3. Current medical history
That is, the reason and process of coming to the hospital, including the onset time, the onset process, the main symptoms, the development and severity of the disease, whether you have received treatment, etc. And systemic symptoms and diseases of other systems.
4. Resume
Including birth history, feeding history, growth and development history, life history and so on. Ask questions according to different ages and different health problems.
(1) Birth history: parity, gestational age, delivery mode and process, maternal pregnancy, birth weight, body length, asphyxia and birth injury, Apgar score, etc. Newborns and babies should know more about it.
(2) Feeding history: Infants with nutritional diseases and digestive system diseases should be asked about the feeding history in detail. Ask about breastfeeding or artificial feeding, what kind of dairy products are mainly used for artificial feeding, how to mix them, the number and amount of feeding, the addition of transitional food, and weaning. Older children should know whether they have bad eating habits such as picky eaters, partial eclipse and snacks.
(3) Growth and development history: Understand the growth of children's physical development indicators such as weight, height and head circumference; The closing time of anterior fontanel and the eruption time and number of deciduous teeth; Great movement and language development; School-age children should also know about their study in school and their relationship with their peers.
(4) Life history: children's living environment, hygiene, sleeping and excretion habits, and whether there are any special behavior problems, such as thumb sucking and nail biting.
5. Past medical history
Including past medical history and vaccination history.
(1) Past medical history: past illness, illness time and treatment effect; Focus on understanding the history of infectious diseases; Carefully know whether there is a history of food or drug allergy.
(2) Vaccination history: name, times, age of vaccination and whether there are any adverse reactions after vaccination.
6. Family calendar
Whether the family has hereditary diseases, allergies or acute or chronic infectious diseases, whether the parents are close relatives, the mother's pregnancy and childbirth history and the health status of other family members.
7. Psychosocial status
The contents include:
① Children's personality characteristics are active or quiet, gregarious or withdrawn, independent or dependent;
② The reaction of children and their families to hospitalization, whether they know the reason of hospitalization, whether they can adapt to the hospital environment, whether they can cooperate with treatment and nursing, and whether they trust medical staff;
③ Parents' age, occupation, education level and health status;
④ the communication way between parents and children;
⑤ Family economic status, living environment and religious belief;
6. School-age children should also ask about their study in school and their relationship with their peers.