Admission record form
Name:No. □□ -□□□□□□□□□
Subjective data of patients:
Objective data of patients:
Evaluation:
Disposal plan:
Doctor's signature:
Consultation date: year month day
Instructions for filling in the form
1. This form is for residents to use when receiving consultation or medical and health services due to acute or short-term health problems. It should be filled in according to the specific situation of residents receiving services for the purpose of truthfully reflecting the whole process of residents receiving services.
2. Subjective information of patients: including chief complaints, consultation questions and health service needs.
3. Objective data of patients: including physical examination, laboratory examination, imaging examination and other results.
4. Evaluation: according to the subjective and objective data of patients, the initial impression of the disease, the diagnosis of the disease or the evaluation of health problems.
5. Disposal scheme: refers to the disposal scheme formulated on the basis of evaluation, including diagnosis scheme, treatment scheme and patient guidance scheme.