上海银都豪锦养老公寓 医务部门管理表格                                                                             健康档案 部门           室号        床号        入住日期              住院号          姓名                                   护理等级                                性别                                   职业                                    出生年月                               工作单位                                民族           籍贯                    供病史者                                家庭地址                               食物、药物过敏：                         主诉：                                                                                                                                                                 现病史：                                                                                                                                                                                                                                                                                                                                                                                                                 既往史：（曾患疾病、家族病史）                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      体格检查：体温          ℃        脉搏              次/分钟        呼吸          次/分钟血压                                 一般情况（1、以写慢性体征为主、2、皮肤、淋巴、心肺、腹、四肢活动情况、神经反射情况）：                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      实验室检查：                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         初步诊断：                                                                                                                                                                                                                                                                                                                                                                                                                                              诊疗计划：                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     医师签名                                              年         月          日