標準電子病例記錄表格式范本引言電子病歷（ElectronicMedicalRecord,EMR）作為現(xiàn)代醫(yī)療體系中信息管理的核心載體，其標準化、規(guī)范化對于提升醫(yī)療質(zhì)量、保障醫(yī)療安全、促進信息共享及醫(yī)療大數(shù)據(jù)應用具有至關重要的意義。一份結構清晰、內(nèi)容完整、數(shù)據(jù)規(guī)范的電子病歷，不僅是醫(yī)療活動的真實記錄，更是臨床決策、教學科研、醫(yī)療付費和法律維權的重要依據(jù)。本范本旨在提供一個通用的標準電子病歷記錄表格式框架，醫(yī)療機構可根據(jù)自身特點及不同科室的專業(yè)需求進行適當調(diào)整與細化，但核心要素與規(guī)范應予以保留。標準電子病例記錄表格式范本一、患者基本信息(PatientDemographicInformation)*姓名(Name):*性別(Gender):□男□女□其他_________*出生日期(DateofBirth):____年____月____日*年齡(Age):____歲*民族(Ethnicity):_________*婚姻狀況(MaritalStatus):□未婚□已婚□喪偶□離婚□其他_________*國籍(Nationality):_________*身份證/護照號碼(ID/PassportNo.):_________(按規(guī)定加密存儲與顯示)*聯(lián)系電話(ContactPhoneNo.):_________(至少一項，包括緊急聯(lián)系人電話)*現(xiàn)住址(CurrentAddress):_________省/市_________市/區(qū)_________街道/鄉(xiāng)鎮(zhèn)_________詳細地址_________郵政編碼*戶籍地址(PermanentAddress):_________省/市_________市/區(qū)_________街道/鄉(xiāng)鎮(zhèn)_________詳細地址_________郵政編碼*職業(yè)(Occupation):_________*工作單位/學校(Employer/School):_________(如無則填寫“無”)*過敏史(Allergies):□無□有_________(過敏原及反應)*血型(BloodType):□A□B□O□AB□不詳Rh(D):□陽性□陰性□不詳*醫(yī)保類型(MedicalInsuranceType):□城鎮(zhèn)職工□城鄉(xiāng)居民□商業(yè)保險□公費醫(yī)療□自費□其他_________*醫(yī)?？ㄌ?InsuranceCardNo.):_________*建檔日期(RecordCreationDate):____年____月____日*病史陳述者(HistoryInformant):□患者本人□家屬(關系:_______)□其他_________可靠程度:□可靠□基本可靠□不可靠二、就診信息(VisitInformation)*就診序號/住院號(Visit/HospitalizationNo.):_________*就診日期和時間(Date&TimeofVisit):____年____月____日____時____分*就診類型(VisitType):□初診□復診□急診□住院□門診手術□體檢*科室(Department):_________*診室/病房(Clinic/RoomNo.):_________*接診醫(yī)師(AttendingPhysician):_________三、病史采集(HistoryTaking)3.1現(xiàn)病史(PresentIllnessHistory)*起病情況(Onset):時間、地點、緩急、可能誘因。*主要癥狀特點(CharacteristicsofMainSymptoms):部位、性質(zhì)、程度、持續(xù)時間、緩解或加劇因素。*病情發(fā)展與演變(Progression&Evolution):癥狀的變化、新癥狀的出現(xiàn)。*伴隨癥狀(AssociatedSymptoms):與主要癥狀同時或相繼出現(xiàn)的其他癥狀。*診治經(jīng)過(PastMedicalCare):發(fā)病以來在何處就診，做過何種檢查(主要結果)，診斷為何，用過何種藥物(名稱、劑量、用法、療程)，療效如何，有無不良反應。*一般情況(GeneralCondition):發(fā)病以來的精神狀態(tài)、食欲、睡眠、大小便、體重變化等。__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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