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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:

 

 
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