中医门诊病历书写模板

中医门诊病历书写模板在具体阐述模板之前，有必要明确中医门诊病历书写的基本原则：1.客观真实：如实记录患者的陈述、医师的检查所见及诊疗措施，避免主观臆断与虚构。2.准确规范：遣词造句力求精准，使用规范的医学术语，特别是中医的病名、证名、症状描述等。3.完整系统：病历内容应包含患者就诊的全部重要信息，从基本情况到四诊资料，从诊断到治法方药，力求系统全面。4.重点突出：围绕主诉，详略得当，突出与疾病相关的关键信息和中医辨证要点。5.及时书写：诊疗结束后应及时完成病历书写，避免遗漏。中医门诊病历书写模板一、基本情况*姓名：___________性别：____年龄：____岁*就诊时间：____年____月____日____时____分*联系方式：________________（可选，确保患者隐私的前提下）*职业：___________初/复诊：______就诊科室：___________*地址（可选）：_________________________二、主诉*指患者就诊时最主要的痛苦或不适，以及持续的时间。要求简明扼要，一般不超过20字。*格式：主要症状（或体征）+持续时间。*示例：咳嗽痰多伴胸闷三日。*主诉：____________________________________________________三、现病史*详细记录患者从发病到本次就诊时，疾病的发生、发展、演变过程以及诊治经过。1.发病情况：记录发病的时间、地点、可能的诱因（如外感、饮食、情志、劳累等）。2.主要症状特点：针对主诉，详细描述症状的部位、性质、程度、频率、加重或缓解因素。例如，疼痛需记录其性质（胀痛、刺痛、隐痛等）、部位、放射痛、与饮食或情绪的关系等。3.病情发展与演变：症状是逐渐加重还是减轻，有无新的症状出现或旧症状消失。4.诊治经过：发病后曾在何处就诊，做过何种检查（如血常规、影像学检查等，简述结果），诊断为何病，用过何种中西药物（具体药名、剂量、用法、疗程），疗效如何，有无不良反应。5.现在症状：详细记录患者就诊时的所有自觉症状及体征，这是辨证论治的主要依据。应围绕“十问歌”内容进行询问，并结合中医理论要点记录：*寒热：有无恶寒发热，或但寒不热，或但热不寒，发热的时间、特点（如潮热、往来寒热）。*汗：有无汗出，汗出的时间、部位、多少，自汗、盗汗、黄汗等。*头身：有无头痛、头晕，头身疼痛的部位、性质；有无肢体麻木、沉重、乏力等。*二便：大便的次数、性状（溏薄、干结、完谷不化等）、颜色、气味，有无里急后重；小便的次数、颜色、量、气味，有无尿频、尿急、尿痛、尿不尽感。*饮食口味：食欲好坏，食量多少，有无偏食；口中有无异常味觉（苦、甜、酸、辣、咸、淡、腻）或气味。*胸腹：有无胸胁胀满、疼痛，心悸、胸闷、气短；胃脘有无痞满、疼痛、喜按或拒按，有无腹胀、腹痛、腹部包块等。*耳目：有无耳鸣、耳聋、目眩、目赤、目痒、视物模糊等。*睡眠：睡眠质量，有无失眠（入睡困难、易醒、早醒）、多梦、嗜睡。*精神：精神状态，有无烦躁、易怒、抑郁、神疲、乏力等。*体力：一般活动能力，有无明显疲劳感。*现病史记录：________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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