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    首頁 > 養老資料 > 養老院老人健康檔案表
    養老院老人健康檔案表

     


    區域
              室號        床號        入住日期               住院號         

    姓名                                   護理等級                                

    性別                                   職業                                    

    出生年月                               工作單位                              

    民族           籍貫                    供病史者                              

    家庭地址                              

    主訴:

                                                                                   

                                                                                    
     

    現病史:

                                                                                    

                                                                                   

     
    既往史:(曾患疾病、既往體質)

                                                                                    

                                                                                    

    體格檢查:

    體溫                  脈搏              /分鐘        呼吸          /分鐘

    血壓                                

    一般情況(1、以寫慢性體征為主、2、皮膚、淋巴、心肺、腹、四肢活動情況、神經反射情況):

                                                                                      

                                                                                       

    實驗室檢查:

                                                                                        

                                                                                        

    初步診斷:

     

                                                                                        

     

                                                                                        

    診療計劃:

                                                                                        

                                                                                        

    醫師簽名:                                                              


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    老人病歷檔案

    姓名:      性別:       年齡:    區域:     房號:     床號:     
    入院時間:        

      訴:                                                                       

                                                                                   

    現病史:                                                                      

                                                                                                      

    既往史:                                                                       

                                                                                   

    婚育史:                                                                                         

    家族史:                                                                       

                                                                                     

    體格檢查情況:

    體溫:                     脈搏:                       呼吸:                             

    血壓:                  身高:               體重:              體表面積:       

    體檢描述:

    皮膚:                                                                         

    淋巴結:                                                                      

    頭顱:                                                                       

    眼部:                                                                        

    耳部:                                                                       

    鼻部:                                                                        

    口腔:                                                                        

    頸部:                                                                          

    胸部:                                                                         

    血管:                                                                           

    橈動脈:                                                                        

    周圍血管征:                                                                     

    腹部:                                                                         

    肛門及外生殖器:                                                               

    脊柱及四肢:                                                                  

    脊柱:                                                                        

    四肢:                                                                         

    神經系統:                                                                    

    病歷摘要:                                                                    

                                                                                  

                                                       醫生簽名:

    首次外出求醫情況記錄:                                                            

                                                                                  

                                                                                  

                                                        醫生簽名:

     

    二次外出求醫情況記錄:                                                            

                                                                                  

                                                       

                                                        醫生簽名:

     

     

    三次外出求醫情況記錄:                                                        

                                                                                  

                                                       

                                                       醫生簽名:

     

                                                   

    四次外出求醫情況記錄:                                                        

                                                                                 

                                                                                  

                                                        醫生簽名:

     

    五次外出求醫情況記錄:                                                            

                                                                                  

                                                       

                                                        醫生簽名:

     

     

    六次外出求醫情況記錄:                                                          

                                                                                 

                                                       

                                                       醫生簽名:

     

     
    疯了一样要了她三天
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