病歷範本
Admission order Admit to the service of Dr. ______ Diagnosis(1): ( malignant intern, terminal stage ) Diagnosis(2): (consiousness change, #1 related) Condition: on critical Vital Sign As ward routine and PRN Activity: stay BED REST Allergy: Naso-gastric tube, Foley tube, new paitent, EKG, irrigation, wrods such as " now!" "imediately!" Diet as tolerated Addmission note #Cheif Complaint: Sleepy and general maliase for ___ weeks #Present Illness: The __ years old male / female was very healthy before. He / She denied any systemic disease. He / She suffered from intern dog life in CGMH since one year ago. There were many naso-gastric tubes, Foely tubes, arterial gas analysis need to be performed and many complaints from either patients or nurses. Also, large number of paper works, daily progression notes and orders were inevitable. Therefore, he / she went to ...