(1) paper size
(2) page settings
(3) layout requirements
(4) case paper style
case production method
Briefly describe the electronic medical
(1) header, footer, and production points in the e-case template
Using Word as an editor to create the Medical record templates, medical record templates should be in line with the "medical and nursing technical operation routine" in the fourth edition of the writing requirements of the case.
①The common format of the header is "name, department, bed number, case number". Some hospitals will be "continued", "medical records", "medical records" and so on are also included, there is no uniform regulations. In order to enter the actual content of the header content does not move back and forth, the header must establish a form, the name, department, bed number, case number box in which, leaving the appropriate space, the doctor will write the patient's name and other content in which the patient can be filled in. Be careful to leave enough space to avoid wrong lines.
② form settings to use Word to provide a form of automatic application of the grid format, so that the printout does not show the structure of the form, so that the medical record is beautiful and generous. In the design of medical records in the form of an input line below can not be deleted, so that the header and the content of the medical record to maintain the appropriate space between.
3 footer should include the name of the hospital and page number, generally should be based on the requirements of each hospital to design.
(2) electronic case template content design points
①Admission record template content should include "general items, the main complaint, the current history" and so on. The beginning of the case for the "admission record", below it for a table, the first six items for a column, and leave a column corresponding to it. In the form of four columns and six rows of the design. With the word provided by the form automatically apply the grid format, adjust the appropriate column width, so that the column width has enough space to enter the contents of the project. This production project is neatly arranged, input content will not move wrongly.
② will be the main complaint, the history of the current disease, personal history, family history, physical examination and other items listed together after the case of writing the entire sequence of processes in the case template set of routes.