Clinical records during hospitalization The clinical records should be written during hospitalization It includes Case record First record of admission Record of the course of disease Record of consultation Record for transferring to new department Record of discharge Record of death Record of surgery
Clinical records during hospitalization • The clinical records should be written during hospitalization • It includes: Case record First record of admission Record of the course of disease Record of consultation Record for transferring to new department Record of discharge Record of death Record of surgery
Case record The case record should be written systemically and completely within 24 h by intern
Case record The case record should be written systemically and completely within 24 h by intern
Formats and contents of case record Case record Name Sex Age Marital status Nation Profession Native place Current address Data of admission Data of case record Source Reliability
Formats and contents of case record • Case record Name Sex Age Marital status Nation Profession Native place Current address Data of admission Data of case record Source Reliability
Chief compliant History of present illness Past illness Systemic review Personal history Marriage Reproductive and gynecologic history Family history
• Chief compliant • History of present illness • Past illness • Systemic review • Personal history • Marriage • Reproductive and Gynecologic history • Family history
Physical examination Temperature Pulse R espiratory Blood pressure General appearance development nutrition(well, moderate, poor) facial expression(acute or chronic, suffering expression, anxiety. fear, calm) position, gait and mental status(alert, obscure, lethargy, coma) cooperative
Physical examination Temperature Pulse Respiratory Blood Pressure • General appearance: development, nutrition (well, moderate, poor) facial expression (acute or chronic, suffering expression, anxiety, fear, calm) position, gait and mental status (alert, obscure, lethargy, coma); cooperative