HISTORYRECORD1ppt课件WhatishistoryrecordTheclinicalrecorddocumentsthepatient',whatplanstheymakeonthepatient'sbehave,whatactionstheytake,,clear,,,evaluatetheimportanceandrelevanceofeachitem,andconstructaclear,concise,,age(dateofbirth),sex,race,occupation,nationality,,thedateofadmission,thetimeatwhichyoutookthehistory,(s)’,plaintshouldincludeage,plaint,:”This70-yearoldmanhashadshortbreathforaweek.”(HPI)anized,plaint(s)onitsvariouscharacteristics:①dateofonset,②plaint,③modeofonset,courseandduration,④location,⑤relationshiptoothersymptoms,bodilyfunc
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