Mẫu bệnh án và các phần trong bệnh án

I. PHẦN HÀNH CHÍNH
1. Họ và tên:...............................................................................................................
2. Tuổi……..Giới tính: Nam / Nữ.
3. Nghề nghiệp:...........................................................................................................
4. Địa chỉ:...................................................................................................................
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5. Thời gian vào viện:................................................................................................
II. LÝ DO VÀO VIỆN
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III. BỆNH SỬ
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IV. TIỀN SỬ
1. Bản thân
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2. Gia đình
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V. KHÁM BỆNH
1. Khám toàn thân
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2. Khám bộ phận
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VI. TÓM TẮT BỆNH ÁN
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Chẩn đoán sơ bộ:.......................................................................................................
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VII. CẬN LÂM SÀNG
1. Yêu cầu
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2. Các kết quả đã có
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VIII. CHẨN ĐOÁN
1. Chẩn đoán phân biệt
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2. Chẩn đoán xác định
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Kết luận chẩn đoán:..................................................................................................
IX. ĐIỀU TRỊ
1. Hướng điều trị
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2. Điều trị cụ thể
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X. TIÊN LƯỢNG
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XI. PHÒNG BỆNH
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