1, generally including the patient's name, gender, race, age, address, etc. ;

2. The present medical history of the chief complaint, it is necessary to describe the main reason of the patient's hospitalization as the chief complaint, refine the cause, time, course and present situation of the illness, and introduce the admission route.

3. Past medical history needs to describe whether the patient has chronic diseases, infectious diseases, surgery, drugs, allergies and blood transfusion.

4. Personal medical history needs to describe the patient's vaccination, travel, smoking and drinking.

5. Family history needs to describe whether there are family clustering diseases or genetic diseases in the patient's family; For example, women also need to describe menstruation;

6. Systematic physical examination includes the simple situation of eight human systems such as circulatory system, respiratory system and digestive system;

7. The specialist physical examination needs to carry out targeted and professional further physical examination on the symptoms of this hospitalization;

8. The auxiliary examination needs to record whether the patient has improved the relevant examination for this inpatient disease and what the result is;

9. The diagnosis needs to record the patient's disease name as detailed as possible, and take the hospitalized disease as the first diagnosis.

Legal basis: Article 2 of the Regulations on the Management of Medical Records of Medical Institutions.

Medical record refers to the sum of words, symbols, charts, images, slices and other materials formed by medical personnel in the process of medical activities, including outpatient (emergency) medical records and inpatient medical records. Form a medical record after filing. Article 4 of the Regulations on the Management of Medical Records of Medical Institutions can be divided into paper medical records and electronic medical records according to the different forms of medical records. Electronic medical records have the same effect as paper medical records.