1、XXX性別：工作單位：年齡：X歲住址：婚姻：X婚供史者：XXX（與患者關(guān)系）出生地：XX入院時間：XXXX年X月X日X時X分民族：X族記錄時間：XXXX年X月X日X時X分名職業(yè):主訴：XXXXXXXXXXXo現(xiàn)病史：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo既往史：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

2、XXXXXXXXXXXXXXo個人史：XXXXXXXXXXXXXXXXX;月經(jīng)史：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX;婚姻史：XXXXXXXXXXXXXXXX;妊娠及生產(chǎn)史：X-X-X-X。家族史：XXXXXXXXXXXXXXXXXXXXXXXXXXo體格檢查T：x.xcP：X次/分R：X次/分BP：x/XmmHg體重：乂Kg一般狀況：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo頭頸部：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

3、XXXXXXXXXXXXo胸部：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo腹部：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo脊柱四肢：XXXXXXXXXXXXXXXXXXXXXXXXXo外陰：XXXXXXXXXXXXXXXo產(chǎn)科檢查XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo骨盆測量：XXXXX

4、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXo高危因素記錄：X。建圍產(chǎn)大卡：X地點：XXXXXXX實驗室及器械檢查XXXXXXXXXXXXXXXXXXXXXXXXoXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo初步診斷：XXXXXXXXXXX醫(yī)師簽名：XXX日上級醫(yī)師職稱及簽名（手工書寫）XXXX年X月X日X時X分首次病程記錄孕婦XXX,X,X歲，X婚，XX,XXXX,今因“XXXXXXXXXXXX，于XXXX年X月X日X時X分入院。其病例特點及診斷依據(jù)總結(jié)如下：一、病例特點：XXXXXXXXXXXX

5、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

6、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo二、初步診斷：XXXXXXXXXX三、診斷依據(jù)：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX四、擬

7、診分析：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo五、診療計劃：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXoXXXX年X月X日上級醫(yī)師職稱及簽名（手工書寫）/醫(yī)師簽

8、名：XXXXXXX年X月X日X時X分XXX副主任醫(yī)師查房記錄XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo上級醫(yī)師手工簽名/醫(yī)師簽名：XXXXXXX年X月X日X時X分術(shù)后病程記錄xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

9、xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxXXXXXXXXXXXXXXXXXXo醫(yī)師簽名：XXXXXXX年X月X日X時X分XXX副主任醫(yī)師查房記錄XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

10、XXXXXXXXXXXXXXXXXXXXXXXXXo上級醫(yī)師手工簽名/醫(yī)師簽名：XXXXXXX年X月X日X時X分XXX主治醫(yī)師查房記錄XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo上級醫(yī)師手工簽名/醫(yī)師簽名:XXXXXXX年X月X日X時X分XXXXXXXXXXXXXXXXXXXXXXXX

11、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX。醫(yī)師簽名：XXXXXXX年X月X日X時X分XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo醫(yī)師簽名：XXXXXXX年X月X日X時X分術(shù)后病程記錄XXX

12、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX醫(yī)師簽名：XXXXXXX年X月X日X時X分XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX醫(yī)師簽名：XXXXXXX年X月X日X時X分XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

13、XXXXXXXXXXXXo醫(yī)師簽名：XXX姓名:性別:年齡：歲婚姻：婚職業(yè):入院日期:手術(shù)日期:出院日期:入院診斷:手術(shù)名稱:出院診斷:入院時情況（簡要病史、陽性體征、有關(guān)實驗室及器械檢查結(jié)果）：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo住院經(jīng)過：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXo出院情況：治愈傷口愈合